Several factors seem to be associated with the effectiveness of checklists for diagnostic safety. First, some studies have shown that checklists are more effective when used by novices compared with experts.8 Thus, checklists may work differently for clinicians with different levels of experience. This finding may be related to the second factor of influence: the level of difficulty of a case.
Checklists seem to help more in complex cases than in simple cases,16 which is similar to studies on the effects of reflection.17 However, the evidence is not conclusive, as one study showed a positive effect on simple cases as well.18 Checklists may be more effective in difficult cases because there is more room for error and for improvement. However, in clinical practice it is often hard to distinguish a simple case from a difficult case.
Most studies that have examined the effect of checklists on diagnostic accuracy were conducted in experimental settings.7,8,10,13,14,16 In such settings, potentially confounding factors such as case mix and complexity of the cases can be controlled. Past studies have also typically recruited medical students and residents, who have lower levels of experience. Furthermore, studies in experimental settings often use complex cases, which reflect a different sample than most clinicians encounter in clinical practice. Lastly, while in experimental studies participants are required to use the checklists on all cases they see, in clinical practice checklists may be used inconsistently.19 Thus, past study designs may have overestimated the effects of checklists on diagnostic performance.
Most studies have not taken into account the potentially negative effects of implementing clinical reasoning checklists in clinical practice. Specifically, the use of checklists can be time consuming10,19 and can result in ordering more laboratory tests and imaging.19