Ho Ping Kong Center for Excellence in Education and Practice, University Health Network, Toronto, Ontario, Canada.
Med Educ. 2013 Mar;47(3):301-8. doi: 10.1111/medu.12080.
Checklists are commonly proposed tools to reduce error. However, when applied by experts, checklists have the potential to increase cognitive load and result in 'expertise reversal'. One potential solution is to use checklists in the verification stage, rather than in the initial interpretation stage of diagnostic decisions. This may avoid expertise reversal by preserving the experts' initial approach. Whether checklist use during the verification stage of diagnostic decision making improves experts' diagnostic decisions is unknown.
Fifteen experts interpreted 18 electrocardiograms (ECGs) in four different conditions: undirected interpretation; verification without a checklist; verification with a checklist, and interpretation combined with verification with a checklist. Outcomes included the number of errors, cognitive load, interpretation time and interpretation length. Outcomes were compared in two analyses: (i) a comparison of verification conditions with and without a checklist, and (ii) a comparison of all four conditions. Standardised scores for each outcome were used to calculate the efficiency of a checklist and to weigh its relative benefit against its relative cost in terms of cognitive load imposed, interpretation time and interpretation length.
In both analyses, checklist use was found to reduce error (more errors were corrected in verification conditions with checklists [0.29 ± 0.77 versus 0.03 ± 0.61 errors per ECG], and fewer net errors occurred in all conditions with checklists [0.39 ± 1.14 versus 1.04 ± 1.49 errors per ECG]; p < 0.01 for both). Checklists were not associated with increased cognitive load (verifications with and without checklists: 3.7 ± 1.9 and 3.3 ± 2.0, respectively; conditions with and without checklists: 4.0 ± 1.8 versus 3.9 ± 2.0, respectively [p = not significant for both]). Checklists resulted in greater interpretation times and lengths (p < 0.01 for all). However, checklists were efficient in terms of the cognitive load invested, interpretation time and interpretation length (p < 0.01 for all).
Among ECG interpretation experts, checklist use during the verification stage of diagnostic decisions did not increase cognitive load or cause expertise reversal, but did reduce diagnostic error.
清单通常被提议作为减少错误的工具。然而，当专家应用清单时，它们有可能增加认知负荷，并导致“专业知识反转”。一种潜在的解决方案是在诊断决策的验证阶段而不是初始解释阶段使用清单。这可以通过保留专家的初始方法来避免专业知识反转。在诊断决策的验证阶段使用清单是否会改善专家的诊断决策尚不清楚。
15 名专家在四种不同条件下解释了 18 份心电图（ECG）：无指导解释；无清单的验证；有清单的验证；以及解释与清单验证相结合。结果包括错误数量、认知负荷、解释时间和解释长度。在两项分析中比较了结果：（i）有和没有清单的验证条件之间的比较，以及（ii）所有四种条件的比较。使用每个结果的标准化分数来计算清单的效率，并根据认知负荷、解释时间和解释长度来权衡其相对收益与相对成本。
在这两项分析中，使用清单被发现可以减少错误（有清单的验证条件中纠正的错误更多[每份心电图 0.29 ± 0.77 与 0.03 ± 0.61 个错误]，所有有清单的条件中发生的净错误更少[每份心电图 0.39 ± 1.14 与 1.04 ± 1.49 个错误]；p < 0.01）。清单与认知负荷增加无关（有和没有清单的验证：3.7 ± 1.9 和 3.3 ± 2.0；有和没有清单的条件：4.0 ± 1.8 与 3.9 ± 2.0；p 均无显著差异）。清单导致更长的解释时间和长度（所有均 p < 0.01）。然而，从认知负荷投入、解释时间和解释长度来看，清单是有效的（所有均 p < 0.01）。
在心电图解释专家中，在诊断决策的验证阶段使用清单不会增加认知负荷或导致专业知识反转，但确实可以减少诊断错误。
