Checklists to improve diagnostic reasoning are not ready for use in clinical practice. Evidence that checklists improve diagnostic accuracy is mixed (see Table 1), and positive effects of checklists on diagnostic accuracy are mainly found in subgroups of cases (difficult cases) or clinicians (junior clinicians). Furthermore, checklists have potentially negative effects, such as time pressure and overdiagnosis, which have been insufficiently studied. Finally, most studies that measure effects on accuracy are performed in controlled settings that do not resemble typical clinical practice, and even the modest benefits of checklists may therefore be overestimated. The fact that most studies already show a limited effect of checklists on diagnostic accuracy in experimental settings does not bode well for the use of checklists in clinical practice.
Conceptually determining whether checklists can be useful for improving diagnostic safety requires answering some critical questions. Can we develop checklists for diagnostic error reduction that focus on errors of execution rather than errors of planning? Are checklists effective when tested in a diverse population (including experienced clinicians) under realistic circumstances and with a realistic case mix? Subsequently, pilot testing of potentially effective checklists in clinical settings is crucial.
While research on the use of checklists in diagnostic safety is still in its infancy, more indepth evaluation, including a focus on implementation factors and the contexts for use, will help answer these and other critical questions and demonstrate if and how checklists can be a viable tool for diagnostic error reduction.
