A couple of years ago I published elsewhere some thoughts about the use of a specific checklist that preceded catheter lab procedures. This so-called WHO checklist, named after that well recognised international body, was initially applied to surgical practice with the intention of reducing mistakes, mishaps, accidents and disasters. It has since been embraced by hospital Trusts in order to cover an increasing variety of activities in which patient safety may be at risk.
In any system, a negative outcome is not so much the result of one major element failing, but consequent more upon the coalescing of a number of minor factors. These apparent