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CHAPTER 11

Guidelines, Checklists and Protocols

Learning Outcomes

By the end of this chapter you should be able to demonstrate an understanding of:

why guidelines, checklists and protocols are used
definitions of guidelines, checklists and protocols
appropriate use of guidelines, checklists and protocols

Introduction

In the 1960s, the aviation industry first started to look at pilot error as a factor involved in airline incidents. There were a number of high-profile air crashes in the 1970s, whose analysis promoted a focus on the role of individual human factors in causation. The Three Mile Island nuclear reactor disaster in 1979 showed that not only individual human factors causing error are of concern, but also those human factors involved in systematic error in management, maintenance and systems. Thus, there is interaction between systematic problems and the individuals who work within that system. This interrelationship between systems and individuals has been illustrated by Professor James Reason (2000) using the Swiss cheese model, a pictorial representation of which is seen in Figure 1.1.

Background Concepts

Problems with patient safety occur in the following situations:

1 Tensions may develop between production and protection. For example, in the emergency department, ‘production’ might be attaining the 4-hour target and thus getting 98% of patients through the department within 4 hours. However, the safety of a patient may be breached clinically if pushed through the system without due care and attention to their clinical needs; they could be sent to either an inappropriate ward, or wrongly discharged home.

2 Latent factors in systems are errors in the system that remain undiscovered. They can include inadequate or inappropriate equipment, poor safety culture, poor design of systems and problems with management and supervision. An example of this would be the old paediatric nasogastric feeding tubes that had interchangeable connections with IV lines. A number of incidents occurred where enteral medications were delivered intravenously. At the current time, there can be little doubt that it would be desirable to modify spinal needles such that it would be impossible to connect IV syringes to them.

3 There is a causational element that combines with the above to trigger an active failure which breaches any barriers or safeguards. This could be a specific individual who may not be trained adequately or who breaks the rules, cuts corners or does not follow the guidelines. For example, not checking the patient correctly for a blood transfusion.

There are a number of ways to prevent safety problems occurring: firstly, to ensure that systems within the National Health Service (NHS) are robust enough to prevent latent failures. Organisational systems and culture were discussed in Chapter 10. Secondly, there must be staff training to improve patient safety and to ensure that personnel are aware of errors that can occur, both technical and non-technical. There must be a ‘no blame’ culture to enable errors to be reported and corrected. There should be standards, adhered to by all, to maintain a high level of performance and thus improve patient safety. These standards may be in professional conduct, for example those from the General Medical Council, in maintaining good medical practice.¹ Other methods to maintain standards are those providing specific medical or procedural guidelines or protocols. Some colleagues have felt this reduces their freedom in exercising clinical skills. However, guidelines rather than protocols have been developed that enable experienced clinicians to provide an alternative, responsible solution to an individual patient’s clinical problem, rather than the standard guidelines where they deem it necessary.

These standards of practice are the same as standard operating procedures, which are defined as a written instruction to achieve uniformity of performance of a specific function (St Pierre et al. 2008).

Practical Strategy and Application

There are a number of types of standard operating procedures, otherwise known as ‘standards of practice’ within healthcare, which are used day to day in the healthcare environment both in routine operations and procedures. There are also guidelines and protocols to be utilised in the emergency environment.

Guidelines

The definition of a clinical practical guideline is that from Field and Lohr (1990), ‘Systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific circumstances.’ Thus, guidelines should be used to support clinicians in their clinical decision-making processes in the management of specific patients. Guidelines must be evidence based and the clinicians must have confidence that these guidelines have been developed from a systematic review of all the evidence available, bringing together a consensus of opinion to provide the best practice for that individual clinical problem. Guidelines provide consistency in treatment, which is often cost effective, and reduces inappropriate treatment of patients. This enables more appropriate referral of patients and thus more efficient use of resources. At the same time, guidelines can be utilised in clinical audit for quality assurance and are used as the basis of continuing medical education. Often, when viewing guidelines or performing a systematic review to develop a guideline, this may well reveal potential areas for research due to the lack of evidence within the literature (Open Clinical 2001).

Frequently, guidelines are now in the form of an electronic or computerised system that enables quick access to specific clinical guidelines in the emergency situation. For example, in the treatment of atrial fibrillation, there are a number of avenues of treatment depending on whether the atrial fibrillation is new onset, paroxysmal or longstanding.

Protocols

A protocol can be described as a standard of care which is much more specific than a guideline and is defined as ‘a comprehensive set of rigid criteria outlining the management steps for a single clinical condition or aspects of an organisation’ (Open Clinical 2001). Protocols are rigid and indicate mandatory practice and are thus used frequently in hospital policies or procedures that are organisationally specific and will have medico-legal implications if breached. It is because of this definition of protocols, and the medico-legal implications, that most departments have clinical guidelines, thus enabling the experienced clinician other options if a specific guideline is not entirely suitable for that particular patient’s clinical condition.

Checklists

The human memory is error prone, specifically in stressful situations or when an individual is fatigued. Thus, checklists can be utilised as an aide-memoire in the healthcare environment. The acute medical environment is often quite complex and a checklist may help to compensate for inadequacies of the human memory. The checklists can be utilised to prepare for routine tasks or anticipate untoward events. There are a number of examples of these in use:

1 The World Health Organisation’s surgical checklist (Haynes et al. 2009). Utilising a checklist at the beginning of a theatre list can prevent or address intraoperative problems early.

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