Answer: When people don't follow it? Better answer: When people don't think they should follow it? Still better answer: When people don't follow it and people are harmed.
Lola Butcher (could we have picked a better teaser of a last name?) writes in Hospital and Health Networks that, according to the head of The Joint Commission, "surgeries on the wrong side of the body, the wrong site or even the wrong patient continue to occur an estimated 40 times every week." She notes that the JC "first highlighted the problem of wrong-site surgery in 1998." Further:
The Joint Commission already requires accredited hospitals and surgery facilities to use a universal protocol that covers preoperative verification, marking of the surgical site and taking a time-out by all members of the surgical team immediately before the procedure begins. The extent to which the protocol is followed varies widely.
While things sounds like a prima facie case of failure on the part of the accreditation body, it is more than that. The clinical director of the Pennsylvania Safety Authority notes that there have been some successes in the country, but:
"When you subtract out the 50 facilities that have been in those collaborations, we don't see any change at all in the remaining facilities," Clarke says. "We do think we have made a difference, but it's only when hospitals actually make a commitment to change their systems.""
The simple truth is that many doctors don't buy in to this. I've heard of some anesthesia writings that cite the statistics indicating the errors continue as evidence that the checklist protocol does not work! These observers completely ignored whether the protocol was actually being followed or not.
Let's go back to The Joint Commission. As I have discussed, failure to pay for such "never" events is not effective. While I am not keen on regulatory interventions, it is possible to use a light, but effective hand that could make a difference. How about starting by publicizing all cases on the public JC website, with the name of the hospital? Keep them in the public eye until a root cause analysis has been done and a remediation plan put in place. Then, share those success stories widely, as opposed to hiding them behind the JC paywall.
If that approach doesn't start to get results, adopt a policy of putting the hospital on probation, in terms of its accreditation, until a root cause analysis has been done and a remediation plan put in place.