How to Build a Checklist That Actually Gets Used
Many EMS providers have been handed a laminated card that someone called a “checklist” and was told to use it. The card was busy, complicated and essentially just a synthesis of the entire protocol. And every EMS provider has, at some point, decided it’s easier to just wing it. That’s a design failure. Glenn Fisher — airline pilot and Aviation Safety Action Program committee member — breaks down exactly why, and what aviation learned the hard way about checklists.
A Checklist Is Not a Protocol on a Card
The single biggest mistake in checklist design is treating it as a miniature version of the full procedure manual. Aviation distinguishes between the manual (everything you need to know, studied ahead of time) and the checklist (only the items that are both likely to be forgotten AND consequential if missed).
Glenn puts it plainly: if you take every step of getting an airplane off the gate — pages and pages of procedures — the resulting checklist is maybe 10 items or less. Those 10 items represent “all of the things that if we didn’t do them, they’re gonna cause significant problems later or harm.”
For EMS, this means an intubation checklist should not be a synthesis of the airway protocol. It should be the 5-8 items that you could realistically forget under stress and that would create a critical failure if you did.
Three Types of Cognitive Aids
Aviation uses distinct tools for distinct cognitive demands:
Flows — memorized sequences performed by habit. You do these regularly and the same way every single time. They become muscle memory through repetition. The following checklist then verifies your flow was complete and that you didn’t miss a step.
Verification checklists — short lists confirming critical items after a flow. One pilot reads, the other checks by physically reaching out and touching the item. This catches the “looked but didn’t see” failure mode.
Read-and-do checklists — used for abnormal situations you haven’t memorized and can’t predict. These are more comprehensive because you’re executing unfamiliar steps in real time. You read the step, then do it.
The error in EMS is collapsing all three tools into one card. A drug-assisted airway checklist is attempting to be both a flow reminder AND a read-and-do procedure AND a verification tool — and accomplishing none well.
Memory Items: What Deserves Memorization
Some actions need to be completed immediately, from memory, before you even pull at the checklist. Aviation identifies “memory items” — the time-critical actions that must happen before you have time to open the book. For a rapid cabin depressurization: don oxygen masks and establish crew communications. That’s it. Everything after that is read-and-do.
The criteria for what gets memorized: Is it time-critical? Would delay be dangerous? If yes, memorize it. Everything else stays in the book because “mistakes could be possibly worse than the problem you’ve got.”
For EMS intubation: the decision to intubate and initial patient optimization might be memory items. Equipment selection and preparation, drug dosing, and post-intubation management belong on the card.
When People Bypass the Checklist, Fix the Process
Glenn references Just Culture by Sidney Dekker: “The takeaway management should have when they see people doing that is not necessarily, ‘Hey, lazy operator, and let’s slap them on the hand.’ It’s probably, ‘Let’s look at our process and see why it is such a pain in the butt.'”
Nobody came to work to hurt a patient. If providers are bypassing a cognitive aid, the aid has failed its design purpose. Aviation learned this through crash investigations where “the corrective action and the learning was, okay, we made this checklist so burdensome and complicated and irritating… everybody was bypassing it.”
Physical Engagement Prevents Confirmation Bias
Even with good checklists, the human brain can “look without seeing.” Glenn describes the Japanese train system’s pointing-and-calling method: conductors physically point at signals and verbally confirm their state. This engages multiple cognitive channels and forces conscious processing.
Practical application: touch the equipment you’re verifying. Point at the monitor reading. Say the value out loud. These behaviors look odd to outsiders but dramatically reduce the “brain fart” failure mode that Glenn describes as unavoidable in any career.
Key Takeaways
- A checklist should contain only items that are (a) likely to be forgotten AND (b) consequential if forgotten — not a miniature protocol
- Separate your cognitive aids: flows for routine, verification checklists for confirmation, read-and-do for abnormals
- If providers aren’t using the checklist, the checklist is broken — investigate process before blaming people
- Physical engagement (point, touch, verbalize) prevents “looking without seeing”
- Memorization should be reserved exclusively for time-critical actions that cannot wait for reference
Further Reading
- The Checklist Manifesto — Atul Gawande
- Just Culture — Sidney Dekker
- Cockpit Checklists: Concepts, Design, and Use — NASA (Degani & Wiener, 1993)
- Design Guidance for Emergency and Abnormal Checklists — NASA (Burian, 2006)
