Monday, September 24, 2012

The Checklist Manifesto

The Checklist Manifesto

I checked out The Checklist Manifesto, by Atul Gawande, as part of an attempt to get my life more organized and better prioritized.  (Let's just say I overcommitted a bit last spring.)  I also have a tendency to write down too many items on my todo lists, and they can lose their usefulness quickly.  I was hoping this would help me to use checklists more effectively.

I was wrong.  Well, mostly.  It turned out to be an argument for *doctors* to use checklists much more regularly in their operations, largely surgeries, in order to avoid forgetting to do obvious things.  As it turns out, there is a need:
"In 2001, [a previous checklist study was performed].  Doctors are supposed to (1) wash their hands with soap, (2) clean the patient's skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a mask, hat, sterile gown, and gloves, and (5) put a sterile dressing over the insertion site once the line is in.  Check, check, check, check, check.  These steps are no-brainers; they have been known and taught for years.  So it seemed silly to make a checklist for something so obvious.  Still, Pronovost asked the nurses in his ICU to observe the doctors for a month as they put lines into patients and record how often they carried out each step.  In more than a third of patients, they skipped at least one."
(pages 37-38, emphasis mine)


All very basic stuff huh?  As a patient, I just kind of assume that these things are happening behind the scenes and that they'd never make a mistake as simple as forgetting to wash their hands.  Evidently not.

In the next year the nurses were encouraged to correct the doctors when they witnessed steps being skipped.  "The results were so dramatic that they weren't sure whether to believe them: the ten-day line-infection rate went from 11 percent to zero." (page 38)  An estimated eight lives saved in one hospital, from making sure medical professionals remembered to sterilize everything!

Gawande then goes on to describe how checklists are used successfully in other fields, and this was surprisingly interesting as well.  For example, construction of large buildings/skyscrapers is evidently done by breaking the design into multiple subsystems, and each team effectively has a giant checklist they're working through.  And to make sure the different teams work nicely with each other, some of the tasks are communication-oriented, e.g. have a cross-team meeting to discuss potential issues after the water lines are put in.  Gawande is advocating a similar approach in medicine; instead of having one exalted physician or surgeon, maybe we should entrust our health to multiple experts and attempt to do a better job communicating amongst themselves.

Aviation was presented as the gold standard in checklists.  Evidently pilots have manuals which consist of hundreds of checklists on the plane every time they fly.  Most are never used, but they'll describe every possible disaster scenario and the really obvious first steps that must be performed.  One objection readers may have here and elsewhere is that in a crisis scenario the expert should be free to perform by intuition and not be restricted by red tape.  Gawande would disagree, to a point.  "The [airline] checklists have proved their worth--they work.  However much pilots are taught to trust their procedures more than their instincts, that doesn't mean they will do so blindly.  Aviation checklists are by no means perfect ... You want to keep the list short by focusing on what he called 'the killer items'--the steps that are most dangerous to skip and sometimes overlooked nonetheless." (pages 121, 123)  And they must be short, in the 5-10 item, ~30 second range.  At this point, the argument goes, you've removed the costliest, most frequent mistakes and it's time to let the experts act on their own and amaze us.

Gawande also believes that this line of reasoning could be extended to just about anything.  Like investing - did you actually read Company X's cashflow statement before buying its stock?  But I was a bit disappointed it wasn't more practical on a personal level.  There are things that fit into this approach, like remembering to pay the credit card bill, but my life is less ... procedural ... than things in this book.

But it was still a fascinating book.  Sometimes I amaze myself at the variety of things I can make myself interested in.  To be fair, this wasn't the first medical book I've read and enjoyed, but it probably was the first analysis of construction that's been written interestingly enough to hold my attention!  And in case you were wondering, Gawande did ultimately come up with a three-part, nineteen item checklist for use in surgeries that has performed well in testing so far.  It's also been winning many converts from skeptical doctors who usually think a bit too highly of themselves and see it as a waste of time, until the checklist saves someone from a (literally) deadly mistake!  Here's a sample of the current checklist:
"Before anesthesia, there are seven checks.  The team members confirm that the patient (or the patient's proxy) has personally verified his or her identity and also given consent for the procedure.  They make sure that the surgical site is marked and that the pulse oximeter--which monitors oxygen levels--is on the patient and working.  They check the patient's medication allergies.  They review the risk of airway problems--the most dangerous aspect of general anesthesia--and that appropriate equipment and assistance for them are available.  And lastly, if there is a possibility of losing more than half a liter of blood (or the equivalent for a child), they verify that necessary intravenous lines, blood, and fluids are ready." (page 140)

Maybe our next visits will be just a little bit safer :)

4.5/5 - I might actually purchase this one someday
Review also posted to LibraryThing

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