I'm watching the Daily Show with Jon Stewart and his guest is Atul Gawande, author of The Checklist Manifesto. I've blogged about him before, and I use checklists for everything but getting out of bed, but I'm still amazed by three things.
One is the difference that checklists make. The hospital that first implemented a checklist system just to stop infections estimated that checklists saved 1500 lives a year. That's staggering. I wonder how many aircraft accidents checklists avert.
Another is the amount of time it has taken this simple safety device to move from one industry to another. Boeing introduced checklists in 1935 after their test pilots forgot to remove a gust lock and crashed a prototype B-17. It makes me wonder what safety or efficiency techniques I could find in other industries and steal to improve mine.
And finally I am surprised by the reticence of people to adopt the system. I shouldn't be, because I've seen myself the machismo that denies the benefits of acknowledging anyone else's expertise. But as Mr. Gawande pointed out, most people have seen their entire lives that people in high profile macho jobs like astronaut work from checklists. Even Han Solo and Chewie used checklists on the Millennium Falcon.
I saw that one too, and heard the claim about the Millennium Falcon checklist. I don't remember it, maybe it was like Calvins:
Buttons . . . check. Dials . . . check. Switches . . . check. Little colored lights . . . check.
— Calvin and Hobbes
Robin: Atomic batteries to power. Turbines to speed.
Batman: Roger. Ready to move out.
Thank you for posting about this book. We have three surgeons and a pediatrician in the family. I think all of them need to read this book. I also think all of them are arrogant enough to dismiss the idea.
Which is the sad truth.
Perhaps there are no old bold surgeons either?
Sarah & dpierce: oh I love those checklists! Please keep the fictional checklists coming.
Mark Richards: That's too bad. The old/bold difference is that it's not the surgeons who die if they make an error. During the interview Gawande mentioned that after using checklists for a trial period, 80% of doctors said they would continue using them, and 93% said they would want the checklist used if they needed an operation.
Whatever story you & your blog are telling - tale of recently lived experience, link through to a story in the press, or your own reflections - it's always a refreshing read. Down to earth!
Absolutely no idea how I came across your blog, but it's most enjoyable. This Swiss-based reader just wanted to say THANKS.
Elwood Blues: it's 106 miles to Chicago, we got a full tank of gas, half a pack of cigarettes, it's dark and we're wearing sunglasses.
Jake Blues: hit it.
Not so much a checklist, but a situation in which a checklist might have been better:
[Bulb on the fuel guage is flashing]
Kowalski: Skipper, look.
Kowalski: It looks like a small incandescent bulb, designed to indicate something out of the ordinary, like a malfunction.
Skipper: I find it pretty and somewhat hypnotic.
Kowalski: That too, sir.
Skipper: Right. Rico, maunal!
[Catches the manual and smashes the bulb with it]
Skipper: Problemo solved.
Then again, the manual is probably more heavy than a simple checklist...
Regarding checklists in medicine- medical practice is extremely decentralized and unregulated compared to what I infer about aviation. Each surgeon and department of surgery does it's own thing, and if a lawsuit arises the question is, "did they follow standard of care?". Standard of care is whatever an expert witness says it is, and what prevails in court depends upon which expert is more persuasive to the the judge or jury that day.
Eventually obvious good new ideas do creep in to become standard of care, but it can take decades when one is trying to herd cats. I cheer for Dr. Gawande; all his books so far are excellent, but he has an uphill battle on this one.
The idea of making a list of things to do and the order to do them in isn't new: us women call it a "recipe". Early examples include a procedure for making beer, on clay tablets thousands of years old. Probably even then there were blokes sneering at the beer-makers for doing it the easy reliable way.
Anonymous @ 1649 :
I don't think a recipe is a checklist. A checklist is not so much a "to do list" as a list of things to check that you've done.
This is why Aviatrix' joke about a "getting out of bed" checklist was funny.
I do love recipes though. And cake. And beer.
Anonymous @ 1649 - good point! This ain't Rocket Surgery - or at least it shouldn't be. It's common sense.
I think this is a good opportunity for the patients to take a stand. From now on I will begin every interview for a potential surgery with the question: "Do you use checklists?" If the answer isn't yes, I'll consider seeking another surgeon.
I loooooooooooooooooooove Calvin and Hobbes.
Good point GeorgeG about the decnetralised nature of medicine.
There's a real philosophical difference between pilots and doctors. Doctors don't like the attitude that much of what they do each day is often a repetition of the same few procedures - which could benefit from checklists.
Aviatrix, I think you had a previous post on this subject - probably talking about the same author - about the drop in catheter infections when nurses took the doctor through a simple checklist beforehand? The real key in that trial was that the nurses were empowered to report if the doctor did not follow the checklist. Without that context, there would be few nurses who would risk their employment on questioning a doctor who didn't exactly follow the right procedure. It's CRM, in other words.
Few regulations for doctors on rest periods, and the number of procedures they might be required to undertake in a set period, also. Tempting for a doctor to cut short the preparation steps for a "simple" procedure like catheter placement when (s)he knows the work is piling up, with the consequences (infection) only occurring a few days later.
Oooh, I HEARD about this! It's the idea of applying aviation-type checklists to medical practice, yes? I love this idea. I love it so much that I've applied checklists to the routine functions of both my fairly open-ended social work job, and my process of making sure I get everything I need to the gym. You aviators have the best logic and SOPs of ANYBODY.
[word verification: "spermo" Good heavens!]
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