February 14, 2007 | Mark Paradies

Correctly using a checklist

When a critical job must be done correctly the first time, every time, a checklist is often implemented. Checklists, when used properly, can make it much more likely that a particular job is completed as it was intended, with no mistakes.

Even when a checklist is in place, mistakes are still sometimes made. The problems with a checklist can take several forms:

1. The checklist was not used at all
2. The checklist was used, but had technical inaccuracies or confusing steps (there is a long list of possible root causes covered here)
3. The checklist was not used as intended

Let’s talk about option #3 above. This problem could occur if:
– The operator completes several steps before checking them off (“checkoff misused”).
– The operator had several actions to perform in a single step (“>1 action / step”).
– The operator lost his place in the checkoff, or forgot what steps had been ordered or reported as complete.

The last one is really the only one that is difficult to correct by making changes to the procedure itself. Losing one’s place in a well-written procedure is a human error that may not have anything to do with the checklist itself. In the Navy, we developed a unique method of combatting this error. We used the highly-technical name, “the circle and X method.” Basically, it was used as follows:

1. When the order to conduct a step was given (“Open valve CH-1”), a circle was drawn around the step number. If there were multiple actions within the step (“Open valves CH-1, CH-2, and CH-3”), a circle was drawn around the individual action.
2. When that step was reported as complete (“Supervisor, CH-1 is open”), an “x” was placed through the circle. It was now OK to move to the next step.

To prevent our procedures from getting destroyed due to multiple uses, we inserted a plastic document protector over that page, and used a grease pencil to make the circles and x’s. It was then erased at the end of the procedure and used again.

This method was be used when there was a supervisor giving orders to operators. If the orders were given over a phone circuit, and there was a local supervisor present, he would also use this method in his local procedure to keep track of what had been ordered and completed. The local supervisor would not “x” his step until it had been completed and reported over the phones.

This method is not at all cumbersome if procedure use is required anyway. It is a good method of minimizing the opportunity for supervisors to make that honest mistake during the conduct of a procedure. It is also important that this policy is defined, so that everyone understands it and conducts it the same way every time. In the Navy, the Engineer had this policy clearly stated in his standing orders.

If you’re having human error problems even when using well-written checklists, consider this method to remove yet one more opportunity for human error to occur.

Root Cause Analysis
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