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Why checklists are like toothbrushes: the development and spread of the Emergency Department safety checklist

22 May 2018

Dr Emma Redfern, ED consultant at the Bristol Royal Infirmary, writes about the creation and development of their Emergency Department (ED) safety checklist which is now being rolled out nationally. This blog is part of the Bristol Firsts series, celebrating Bristol-based innovations in the NHS’s 70th year. If you have an idea for a Bristol Firsts blog, get in touch with Zoe Trinder-Widdess on

Imagine standing in an overcrowded Emergency Department as the consultant on call. It’s 1am and your shift was supposed to end several hours ago. Imagine thinking you couldn’t tell at that moment in time which of the 60 patients were unwell and deteriorating.

In 2012, this was a regular occurrence. All the beds in the hospital were full, more patients were being admitted than discharged, and the bottle neck was the Emergency Department (ED).

We had no system to provide basic care, and the scene resembled that of a gruesome ‘Where’s Wally?’, where the ‘Wally’ in question was an unwell person, lying on a trolley, sometimes in a corridor. We relied on the help of nurses from other wards in the hospital, but they were unfamiliar with the ED, and didn’t really know what to do.

For some conditions such as stroke, heart attack or sepsis, a speedy diagnosis can save your life. In the winter of 2012, several ‘serious incidents’ happened and patients came to harm due to the chaos. This was the line in the sand, we knew we had to do something to try to improve the situation to recognise deteriorating patients and treat them quickly.

We decided on a checklist and successfully applied for a small research grant from the Health Foundation. The aim was to standardise the provision of basic care, with resilience in times of crowding and with a sub-optimal skill mix of nurses.

After talking to the nurses, and patients and their families, we designed our checklist; it was a time based framework of tasks that needed to be completed. We tested 29 versions before we got it right. Brevity is key; only include absolutely essential components.

Initially implementation went well, but then the challenges started. Folk do not like change. I know this is a sweeping generalisation, but it is true. We realised that the lead nurses were critical to the success of the project, and tried to engage, teach and learn from every mistake.

At one point, we almost stopped; it was so busy, driving through the change without any demonstrable results seemed pointless. But then the data collection started to show positive results - we were improving the quality of delivery of care. It worked!!!! Standardising the care we delivered improved the quality and, six months in, we had no serious incidents where we hadn’t picked up a deteriorating patient.

But this was in one hospital. The question was, were these results transferrable to other EDs?

We teamed up with the West of England Academic Health Science Network (AHSN). Through their Patient Safety Collaborative’s deteriorating patient programme, the ED checklist was picked up and rolled out by six other EDs across the Westcountry.

We learned that checklists are like toothbrushes: everyone wants one, but no one wants anyone else’s. We set shared ‘key performance indicators’ so we could compare results, but allowed parts of the checklist to be bespoke to the unit.

As we supported the EDs, we saw almost the same challenges happen. Did I mention folk don’t like change?

But the results began to speak for themselves, and all the comparable data points on the graph started to shift in a positive direction.

We submitted an application for the Health Service Journal’s ‘Safety in A&E’ award in 2017. We travelled to London to deliver our presentation, and DISASTER!!! None of the slides worked. So we returned to Bristol feeling a bit glum.

I sat with the West of England AHSN team at the table at the awards ceremony in a posh venue in Manchester in July 2017. The A&E safety award was first up. I didn’t feel nervous, because after the slides debacle, I didn’t think we were in the running. And then the gold envelope opened and our project was called out... I looked in disbelief at the CEO sitting next to me. We had won?

Winning the award gave the checklist national attention. NHS Improvement got in touch and wanted to know if they could apply the principles to other EDs. In October 2017, a letter was written to all medical directors advising that the ED checklist should be used unless there was an equal alternative.

We then supported two meetings and two webinars to share with others our learning and top tips for quick and painless (!!) implementation.

Evaluation is under way by NIHR CLAHRC West, but currently the ED checklist is forming part of the ‘Getting it right first time’ work for Emergency Departments.

The project will have saved lives, but it’s difficult to know how many.

A proper rollercoaster experience. Did I mention folk don’t like change?

Find out more about the ED safety checklist at

Follow Emma Redfern on Twitter at @emmaredfern5

Why checklists are like toothbrushes:  the development and spread of the Emergency Department safety checklist
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