IMSAFE: A Checklist for Safer Nursing Practice
- Cynthia and Laura Love
- Jun 19
- 5 min read
When the Institute of Medicine published its landmark report To Err Is Human, it sent a clear message: the status quo in healthcare was no longer acceptable. The report highlighted the urgent need for systemic change to ensure the delivery of high-quality care and the implementation of stronger safety controls. One industry that had already embraced such measures was aviation. Aware of the potentially catastrophic consequences of failure, aviation had developed robust protocols to safeguard both workers and passengers. Drawing inspiration from this model, healthcare began adopting aviation-style checklists and structured tools that have since demonstrated effectiveness in enhancing patient safety and improving care quality (Powell-Dunford et al., 2017a).
The History of IMSAFE
Aviation recognized that crew resource management (CRM) was crucial to the industry's success. IMSAFE is a mnemonic that originated in aviation safety protocols, used by pilots to assess their fitness before a flight. The Federal Aviation Administration (FAA) and other aviation training programs developed the checklist to help pilots reduce risk by evaluating personal factors that could impair performance. Recognizing its effectiveness in high-reliability fields, the healthcare industry, particularly in anesthesia and emergency medicine, adopted and adapted the tool (Powell-Dunford et al., 2017b). Today, IMSAFE serves as a vital reminder that human factors can significantly impact care quality and safety.
What Does IMSAFE Stand For?
I – Illness: Are you feeling unwell or sick?
M – Medication: Are you taking any medications that could impair your judgment or performance?
S – Stress: Are you under personal or professional stress that could distract you?
A – Alcohol: Have you consumed alcohol within the past 8 hours (or longer, depending on effects)?
F – Fatigue: Are you rested and alert enough to do your job safely?
E – Eating/Elimination: Have you nourished yourself properly and taken care of basic bodily needs? (AHRQ, 2023).
Why IMSAFE Matters in Nursing
Nurses are essential to the safe delivery of care, yet they’re also at risk of burnout, compassion fatigue, and human error, especially when working while unwell or emotionally compromised. IMSAFE empowers nurses to pause and evaluate their fitness for duty, just like a pilot would before takeoff.
This self-assessment doesn't imply weakness or lack of commitment. In fact, it's the opposite: It’s a professional act of accountability that supports safe practice, teamwork, and ultimately, better outcomes for patients.
Applying IMSAFE in Daily Practice
In huddles or shift reports, encourage team members to review the IMSAFE checklist mentally.
Model self-awareness by openly acknowledging stress or fatigue and taking action (asking for help, breaks, etc.).
Promote a culture of psychological safety, where nurses feel supported when they speak up about their limits.
Integrate IMSAFE into wellness initiatives or staff development programs.
Develop Your Checklist
Nursing teams can also take the initiative to develop their safety checklists. By collaborating with leadership and involving nurses at all levels, it’s possible to gather detailed, unit-specific insights, moving beyond generalizations to create meaningful, targeted protocols. These customized checklists can enhance the work environment and elevate the quality of care delivered.
Weiser et al. (2010) outline a five-step framework for checklist development, which can be adapted to help nurses prepare holistically for their workday:
Content and Format: Keep it simple and practical. Include key items that address mental focus (e.g., “Have I reviewed my assignment?”), physical readiness (e.g., “Am I hydrated and nourished?”), and emotional balance (e.g., “Have I done a quick grounding or deep-breathing exercise?”).
Timing: Use the checklist before each shift begins—perhaps during the moments just after clocking in or during your walk to the unit. Like pilots preparing for takeoff, this is your moment to set the tone.
Trial and Feedback: Test the checklist for a few days and reflect. Are you starting your shift with more clarity or calm? Consider using the Plan-Do-Study-Act (PDSA) method to fine-tune it.
Formal Testing and Evaluation: Look for signs that your checklist is working. Do you feel less rushed, more grounded, or better able to prioritize and respond during busy moments?
Local Modification: Personalize the checklist to fit your role, specialty, or even time of day. What works for a night-shift ICU nurse may differ from what’s helpful on a day-shift med-surg unit. Make it yours.
By taking a few moments to prepare—mentally, physically, and emotionally, intentionally—you set yourself up for a more focused, balanced, and resilient shift.
Pre-Shift Readiness Checklist for Nurses
Inspired by aviation checklist principles outlined in the article written by Weiser et al., 2010. Use this checklist before each shift to support focus, calm, and preparedness.
1. Mental Preparation
I’ve reviewed my patient assignment.
I am aware of the priorities and likely challenges associated with my shift.
I’ve mentally reviewed standard protocols and critical updates.
I’ve taken a moment to visualize a calm and productive shift.
2. Physical Readiness
I’m adequately hydrated.
I’ve had a nourishing meal or snack.
I’ve used the restroom and verified that I've all the necessary gear (badge, stethoscope, pens, etc.).
My shoes and uniform are comfortable and appropriate for the demands of the day.
3. Emotional & Mindful Grounding
I’ve taken three deep breaths or done a 1-minute mindfulness pause.
I’ve reminded myself of my purpose or set a positive intention (e.g., “I will stay calm under pressure.”).
I’ve checked in with myself emotionally and acknowledged how I’m feeling.
I’ve briefly connected with a teammate or support person as needed.
4. After-Shift Reflection (Optional)
Did this checklist help me feel more prepared?
What worked well today?
What would I change or add to this checklist?
Closing Thought about Checklists and IMSAFE
As nurses, we advocate for others constantly, but IMSAFE reminds us to check in with ourselves. When we’re safe, supported, and self-aware, we are better equipped to care for those who need us most.
Please let us know if your healthcare team develops a safety checklist and how you evaluate its success.
References
Agency for Healthcare Research and Quality. (2023). Tool: I’M SAFE checklist. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/teamstepps-program/curriculum/situation/tools/safe.html
Powell-Dunford, N., McPherson, M.K., Pina, J.S., & Gaydos, S.J. (2017a). Transferring aviation practices into clinical medicine for the promotion of high reliability. Aerospace Medicine and Human Performance, 88(5), 487-491
Powell-Dunford, N., Brennan, P.A., Peerally, M.F., Kapur, N., Hynes, J.M. Hodkinson, P.D. (2017b). Mindful Application of Aviation Practices in Healthcare. Aerospace Medicine and Human Performance, 88(12), 1107- 1116.
Weiser, T. G., Haynes, A. B., Lashoher, A., Dziekan, G., Boorman, D. J., Berry, W. R., & Gawande, A. A. (2010). Perspectives in quality: designing the WHO Surgical Safety Checklist. International journal for quality in health care : journal of the International Society for Quality in Health Care, 22(5), 365–370. https://doi.org/10.1093/intqhc/mzq039
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