The Checklist Manifesto

Continuing my love affair with Atul Gawande, his book The Checklist Manifesto: How to Get Things Right is an enjoyable and persuasive book. Summarized:

There are two types of failure: ignorance (not knowing enough) and ineptitude (not using what we know well enough). For most of history, ignorance has been the bigger problem in medicine; now ineptitude is. According to the World Health Organization, there are more than 13,000 different diseases, syndromes, etc. There are also 6,000 drugs that we can use and 4,000 procedures that we can do to try to help. Even with specialization, this is a huge variety of problems and solutions.

The average stay in an ICU is 4 days, and the survival rate is 86%. That’s pretty good given how serious your condition has to be to get admitted to one, and according to a study done fifteen years ago, the average ICU patient required 178 individual actions per day…and two of these actions involve errors of some kind. Of course this is a 99% success rate, but two errors a day is still quite dangerous.

Ever since a Boeing Model 299 crashed during a test flight (the pilot was an Army air corps test pilot with loads of experience), aviation has used careful checklists to handle the complexity of flying a plane and responding to emergencies in midflight. The main thrust of the book is to extend the use of checklists to medicine.

In 2001, Peter Pronovost designed a simple five-step checklist to prevent central line infections. At the time, these steps were well known, but one-third of the time, at least one step was missed. They tried using it for a year at Johns Hopkins hospital, and reduced the central line infection rate from 11% to 0%. Statistically, the checklist saved eight lives and $2 million.

Checklists are also used in construction. When problems arise, a separate checklist is used to ensure that all people involved have communicated and the best course of action is agreed upon.

The culmination of the book is the development of the Safe Surgery Checklist. Eight hospitals around the world tried it out for three months, and surgery complications went down by 36% and deaths went down by 47%.

I feel that summarizing the book isn’t quite doing it justice – it’s a fascinating read. But the results are so amazing, it makes me want to stand up and scream for all hospitals to use the Safe Surgery Checklist!

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