We read with interest the article by Fuchs et al. [1]. The authors discussed the use of a pre-induction checklist in their institution as part of an initiative to reduce airway-related incidents. We commend their efforts to introduce risk-reduction measures and their improved adherence to the use of their checklist during the study.

As stated in the article, checklists in healthcare have been shown to be beneficial in specific settings. For instance, the use of a pre-induction checklist has been shown to reduce tracheal intubation attempts in the pre-hospital setting. They have also been shown to reduce serious complications of tracheal intubation in the ICU [2]. Healthcare providers working in these areas perform airway management less frequently than theatre-based anaesthetists and, therefore, may benefit more from the use of an aide-memoire.

However, the evidence for pre-induction checklists in the operating theatre is currently lacking. In their own words, Fuchs et al. state they “could not find any effect of the use of the checklist on patient outcomes” [1]. A systematic review and meta-analysis by Turner et al. [3] showed that pre-induction checklists in theatre are not associated with improved clinical outcomes. This may reflect the fact that anaesthetists primarily manage airways in a controlled environment set up expressly for airway management. Added to this, patient, equipment and drug checks are already well established in our practice and, as their study showed, the vast majority of our airway management occurs in the controlled, elective theatre setting [1].

As a specialty, we strive towards being considered a high-reliability industry and maintain patient safety at the forefront of everything we do. As a result, it is perhaps inevitable that we will move towards a system that involves greater standardisation and, with that, a barrage of checklists. However, before we accept these checklists into our everyday practice, or mandate them, we need to think about how they are integrated into pre-existing checks. As Griggs suggested, we must design systems that talk to each other and reduce repetition and redundancy; “checklists need to present the right list at the right time with the right content” [4]. Without careful attention to the design of integrated systems, we risk precipitating checklist fatigue. Furthermore, introducing additional, potentially unnecessary, checklists run the risks of becoming counterproductive. For example, one study examining the introduction of nurse-led tracheal extubation checklists in the ICU was shown to extend the patients' time on a ventilator, ICU and hospital admission duration [5].

In the COVID-19 era, with expanding surgical waiting lists and additional pressures on staff, we must consider what checklists we choose to introduce and how they are integrated; they must improve clinical performance without causing inefficiency. In our opinion, we need to change the focus from adherence to checklists to system design and education for this to happen.

我们感兴趣地阅读了 Fuchs 等人的文章。[ 1 ]。作者讨论了在他们的机构中​​使用诱导前检查表作为减少气道相关事件的举措的一部分。我们赞扬他们为引入降低风险措施所做的努力，以及他们在研究期间更好地遵守使用他们的清单。

如文章所述，医疗保健清单已被证明在特定环境中是有益的。例如，使用诱导前检查表已被证明可以减少院前环境中的气管插管尝试。它们还被证明可以减少 ICU 气管插管的严重并发症 [ 2 ]。在这些领域工作的医疗保健提供者执行气道管理的频率低于基于剧院的麻醉师，因此可能会从使用备忘录中受益更多。

然而，目前缺乏在手术室进行入院前检查清单的证据。用他们自己的话说，Fuchs 等人。声明他们“没有发现使用清单对患者结果有任何影响”[ 1 ]。Turner 等人的系统评价和荟萃分析。[ 3 ] 表明，手术室中的诱导前检查表与改善临床结果无关。这可能反映了麻醉师主要在专为气道管理而设置的受控环境中管理气道的事实。除此之外，患者、设备和药物检查在我们的实践中已经很好地建立起来，正如他们的研究表明的那样，我们绝大多数的气道管理都发生在受控的、选择性的剧院环境中 [ 1 ]。

作为一个专业，我们努力被认为是一个高可靠性的行业，并将患者安全放在我们所做的一切的最前沿。因此，我们可能不可避免地会朝着一个涉及更大标准化的系统迈进，随之而来的是一连串的清单。然而，在我们将这些清单纳入我们的日常实践或强制执行之前，我们需要考虑如何将它们整合到预先存在的检查中。正如格里格斯所建议的那样，我们必须设计能够相互交流并减少重复和冗余的系统；“清单需要在正确的时间以正确的内容呈现正确的列表” [ 4]。如果不仔细注意集成系统的设计，我们就有可能导致清单疲劳。此外，引入额外的、可能不必要的清单可能会适得其反。例如，一项研究在 ICU 中引入了护士主导的气管拔管检查表，结果表明患者使用呼吸机的时间、ICU 和住院时间延长了 [ 5 ]。

在 COVID-19 时代，随着手术等候名单的扩大和工作人员的额外压力，我们必须考虑我们选择引入哪些清单以及如何整合它们；他们必须在不导致低效率的情况下提高临床表现。在我们看来，我们需要将重点从遵守清单转向系统设计和教育，以实现这一目标。