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Doctor, Did You Check Your Checklist?

Bara Vaida with an interesting article on complexity, human nature, checklists, and improving medical care.

“We are humans and are destined to make mistakes,” says Nancy Foster, vice president of quality and patient-safety policy at the 5,000-member American Hospital Association. “The question in health care is: Can we design processes and have them in place so when an individual makes a natural mistake, that mistake doesn’t result in harm to patients?”

I spoke with a dozen hospitals in the region to ask what they're doing to address patient safety. All are working on strategies—including using checklists to ensure that hospital employees consistently follow safety standards, ramping up pressure on employees to wash their hands, flattening hierarchies to improve communication between doctors and nurses, designing equipment to reduce errors, and digitizing patient records.

Culture of Authority

Because of the hierarchical nature of hospitals, in which the senior doctor is the leader, there often hasn’t been a culture of collaboration and teamwork, Haraden says. That’s been an obstacle to improving patient safety, because while doctors are expected to be confident about their decisions, they also have to accept that oversights can happen and that sometimes a nurse or another colleague might know better.

Haraden, who travels the world speaking to doctors and hospitals about changing their culture, says the only way to get people to change is by showing them data that underscores how standards and teamwork reduce errors. Then leaders of hospitals have to make it clear that they expect their staff to follow the protocols, and hospitals need to report information about errors so the public can compare their safety records.

Learning ‘Dumb' Checklists

Some of the data Haraden uses in her talks comes from Atul Gawande’s 2009 book, The Checklist Manifesto: How to Get Things Right, in which Gawande, a surgeon at Brigham and Women’s Hospital in Boston, ponders his own fallibility and explores how to help others in health care.

“Avoidable failures are common and persistent, not to mention demoralizing and frustrating,” Gawande writes. “We need a different strategy for overcoming failure. And there is such a strategy—though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies. It is a checklist.”

To create his list, Gawande looked to the aviation industry, a high-risk sector that has become reliably safe in part because everyone uses checklists. The military began using aircraft checklists in the 1940s when the complexity of planes reached the point that pilots couldn’t remember every step needed to fly the plane.

As Gawande describes it, the checklist included seemingly “dumb” things such as making sure brakes were released, doors and windows were shut, and instruments were set. But when something becomes habitual and mundane, it’s easy to forget. And overlooking any of those steps could cause a plane to crash.

Today there are multiple checklists for each aspect of airplane operation, including what to do if something goes wrong, such as an engine failure during flight.

Aviation checklists also encourage discussion and spread power among those in charge, creating a sense of teamwork. Assisting pilots participate in checklists and are encouraged to question their commanding officers if they sense there’s danger. The idea is that there’s “wisdom in the group” over the individual, writes Gawande: “Man is fallible, but maybe men are less so.”

Gawande took what he had learned from the aviation industry and worked on a checklist that covered mundane but essential tasks and fostered communication. He developed the list with other doctors through the World Health Organization, and the tool was deployed in eight hospitals worldwide in 2008. The results were telling. Hospitals that adopted his checklist reported a 36-percent drop in major surgical complications and a 47-percent decline in deaths, according to Gawande.

The hospitals reported that the list provided backup protection against lapses in memory due to fatigue or distractions. It also encouraged preoperative discussions, which came in handy when the unexpected occurred during surgery. “No one checklist could anticipate all the pitfalls,” Gawande says, so just having hospital staff stop to talk through a case and its potential challenges reduced complications and deaths.

Curious about checklists? Read The Checklist Manifesto: How to Get Things Right.

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