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Context Checklists are commonly used in the assessment of procedural competence. However, on most checklists, high scores are often unable to rule out incompetence as the commission of a few serious procedural errors typically results in only a minimal reduction in performance score. We hypothesised that checklists constructed based on procedural errors may be better at identifying incompetence. Objectives This study sought to compare the efficacy of an error-focused checklist and a conventionally constructed checklist in identifying procedural incompetence. Methods We constructed a 15-item error-focused checklist for lumbar puncture ( LP) based on input from 13 experts in four Canadian academic centres, using a modified Delphi approach, over three rounds of survey. Ratings of 18 video-recorded performances of LP on simulators using the error-focused tool were compared with ratings obtained using a published conventional 21-item checklist. Competence/incompetence decisions were based on global assessment. Diagnostic accuracy was estimated using the area under the curve ( AUC) in receiver operating characteristic analyses. Results The accuracy of the conventional checklist in identifying incompetence was low ( AUC 0.11, 95% confidence interval [ CI] 0.00-0.28) in comparison with that of the error-focused checklist ( AUC 0.85, 95% CI 0.67-1.00). The internal consistency of the error-focused checklist was lower than that of the conventional checklist (α = 0.35 and α = 0.79, respectively). The inter-rater reliability of both tools was high (conventional checklist: intraclass correlation coefficient [ ICC] 0.99, 95% CI 0.98-1.00; error-focused checklist: ICC 0.92, 95% CI 0.68-0.98). Conclusions Despite higher internal consistency and inter-rater reliability, the conventional checklist was less accurate at identifying procedural incompetence. For assessments in which it is important to identify procedural incompetence, we recommend the use of an error-focused checklist. [ABSTRACT FROM AUTHOR]