Table 1

Simple versus complex narratives in checklist rationale, design and use

	Simple narrative	Complex narrative
Rationale	Checklists reduced aircraft accidents	Aircraft accidents were reduced through a range of physical and procedural design changes, of which checklists were one component
	They ‘plug the holes’ in the Swisscheese9	There are many solutions to a problem; checklists may solve problems and/or introduce new ones
	They encourage safer behaviour	They may encourage ‘mindless’ checking, promote automaticity and discourage conceptual thinking about a task
	They reduce undesirable human variability	Variable human responses address contextual variability, essential for safety system function
	They are ‘evidence based’	They are one part of the underlying mechanism of effect, which is often poorly defined
	They are an exemplar of ‘systems thinking’	They are used to modify behaviour instead of applying broader systems thinking
	They encourage teamwork and communication	They can help to promote shared awareness and team discussions where sufficient team skills and a supportive working environment already exist, but cannot achieve this alone
	They are for checking something is correct	They are for checking something has been done
	They encourage ‘pause for thought’ or discussion	They are most effective when requiring immediate stimulus-response behaviour
	They reduce the effects of interruptions	They are most error-prone when interrupted
Design	They are a simple piece of paper	They are a complex socio-technical intervention
	They can be developed easily	They take considerable effort to be effective, with many design dimensions to consider
	They are a ‘stand-alone’ solution	A checklist is part of a wider engineered process, including other checklists
	They define how a task should be performed	The user should be skilled and well practiced at the task. A checklist should assist them in doing it
	They are a simple set of statements and boxes	There are a wide range of design parameters
	They must have a tick box	A tick box is not always necessary and does not guarantee full or proper use
	Text is descriptive of desired performance	The text should be a reminder for a motivated user, already skilled and experienced in the task
	They should be ordered in terms of function (ie, All similar process items together)	They should be ordered in terms of geographical and temporal proximity (ie, tasks done in the same time and space)
	They can be used for general tasks (‘empower staff’)	They should be used for specific tasks (‘manual start switch…off’)
Use	They can be implemented easily	Implementation is a complex and challenging process that also requires ongoing maintenance
	They are a cost-effective solution	The resources required to implement, perform and maintain a checklist are rarely calculated
	They need to be followed by everyone	A challenging dichotomy arises where experts, who may perceive them as wasteful and patronising, use them as a reminder only. This may or may not be appropriate
	They should always be complied with	A poor design, implementation or context might make it impossible to be compliant
	They should be signed	Signing does not guarantee appropriate use, accountability, compliance or audit accuracy, and can promote ‘gaming’ and false views of safety
	Lack of professionalism and a culture of safety are the causes of non-compliance	Non-compliance may be because of inappropriate designs, use cases, implementation, training, perceived utility, threats to professional identity/autonomy/expertise, power-play by managers and time/cost burdens incongruent with other system demands
	Their use can be easily and reliably audited	Real-time observations of checklist use typically reveal lower levels of compliance than those suggested by organisational audits. True compliance refers to ‘how’ checklists are being used, not just ‘if’, and this should be measured to maximise understanding of the barriers and facilitators to uptake and buy-in