A hospital, as the saying goes, is no place for sick people. It’s filled with hazards to your health, not least of which are the myriad infections, missed diagnoses, dosage mistakes and other complications that arise from human error. And, in a hospital, human error seems all but inevitable. How can any one individual, or even any one team of individuals, keep all the tasks straight and anticipate all eventualities 100 per cent of the time?
But Dr Peter Pronovost, a critical care specialist at the Johns Hopkins medical centre in Baltimore, thought he knew how to minimise human error. It was, as Dr Atul Gawande describes it in his provocative new book, The Checklist Manifesto, an idea so simple that it seemed downright loopy.
In 2001, Dr Pronovost borrowed a concept from the aviation industry: a checklist, the kind that pilots use to clear their planes for takeoff. In an experiment, Dr Pronovost used the checklist strategy to attack just one common problem in the ICU, infections in patients with central intravenous lines (catheters that deliver medications or fluids directly into a major vein). Central lines can be breeding grounds for pathogens; in the Hopkins ICU at the time, about one line in nine became infected, increasing the likelihood of prolonged illness, further surgery or death.
Dr Pronovost wrote down the five things that doctors needed to do when inserting central lines to avoid subsequent infection: wash hands with soap; clean the patient’s skin with chlorhexidine antiseptic; cover the patient’s entire body with sterile drapes; wear a mask, hat, sterile gown and gloves; and put a sterile dressing over the insertion site after the line was in.
“These steps are no-brainers; they have been known and taught for years,” writes Dr Gawande, a surgeon at Brigham and Women’s Hospital in Boston and a staff writer at The New Yorker, where a version of The Checklist Manifesto first appeared in late 2007. “So it seemed silly to make a checklist for something so obvious.”
But Dr Pronovost knew that about one-third of the time doctors were skipping at least one of these critical steps. What would happen if they never skipped any? He gave the five-point checklist to the nurses in the ICU and, with the encouragement of hospital administrators, told them to check off each item when a doctor inserted a central line — and to call out any doctor who was cutting corners. As Dr Gawande relates it, “The new rule made it clear: if doctors didn’t follow every step, the nurses would have backup from the administration to intervene.”
The nurses were strict, the doctors toed the line, and within one year, the central line infection rate in the Hopkins ICU had dropped from 11 per cent to zero. Two years after the checklist was introduced, Dr Pronovost calculated, it had prevented 43 infections, avoided 8 ICU deaths and saved the hospital approximately $2 million.
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Based on this success, Dr Pronovost and his colleagues wrote up checklists for other situations in the ICU, like mechanical ventilation. The average length of stay in the ICU dropped by half, and 21 fewer ICU patients died than had died the previous year.
The story of the Hopkins ICU will be familiar to loyal fans of Dr Gawande’s amazing New Yorker article, which was quintessential Gawande: elegantly written and elegantly conceived, in which the writer finds a surprising, slightly askew way of looking at familiar medical issues.
Perhaps Dr Gawande believes that the point he made in his original article bears repeating, since it’s been hard for people to accept its central tenet: that the complexities of technology in the 21st century may be best handled by the simplest solution. “We may admit that errors and oversights occur — even devastating ones,” he writes, referring here primarily to his fellow surgeons, a group not known for modesty. “But we believe our jobs are too complicated to reduce to a checklist.”
Dr Gawande personally faced his share of these sceptics, as he writes in the second section of the book, during his work with the World Health Organisation bringing the checklist idea to hospitals around the world. In eight hospitals as varied as a remote rural installation in Tanzania serving one million people and a high-tech university facility in Seattle, Dr Gawande and a team of public health experts and surgeons applied basically the same 19-point checklist. The study and the results were startling. Without adding a single piece of equipment or spending an extra dollar, all eight hospitals saw the rate of major post-surgical complications drop by 36 per cent in the six months after the checklist was introduced; deaths fell by 47 per cent.
If something as simple as a list that reminds medical personnel to wash their hands and introduce themselves by name and job to everyone in the operating room can improve care, that’s reason enough to take the checklist concept seriously.
THE CHECKLIST MANIFESTO
How to Get Things Right
Atul Gawande
Metropolitan Books
209 pages; $24.50
