Checklists: Silly, Obvious … and Life Saving

Review of The Checklist Manifesto by Atul Gawande

 “It seems silly to make checklists for something that is so obvious.”

In his eye-opening book, The Checklist Manifesto, author Atul Gawande documented this sentiment in industry after industry – among doctors, nurses, firefighters, police, lawyers, financial managers, pilots, EMS teams, and sometimes even our military. But when checklists are employed and adhered to, the results are astounding.

Checklist Manifesto digs into why this process is so important.

In a complex environment, [there are] two main difficulties. The first is the fallibility of human memory and attention, especially when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events.

…  Just as insidious, is that people can lull themselves into skipping steps even when they remember them … Perhaps the elevator controls on airplanes are usually unlocked and a check is pointless most of the time … “This has never been a problem before,” people say. Until one day it is.

Checklists seem to provide protection against such failures. They remind us of the minimum necessary steps and make them explicit. They not only offer the possibility of verification but also instill a kind of discipline of higher performance.

One of the impressive cases early in Manifesto that Gawande reports was from a Johns Hopkins Hospital, where a critical care specialist decided to give a doctor checklist a try after he witnessed several tragedies. It was simple stuff.

On a sheet of plain paper, [the critical care specialist] plotted out the steps to take to avoid infections when putting in a central line [into an artery or vein]. 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 … These steps are no-brainers; they have been known and taught for years.

Anybody with some common sense knows to follow these steps, but Gawande reported on how often they were not implemented, for a variety of reasons that involved human nature and short-sighted budgeting. By using a checklist – and having the necessary conversations brought on by their insights — compliance increased and …

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. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections, eight deaths and saved two million dollars in costs [and other similar measures]. It reduced from 41 percent to 3 percent the likelihood of a patient’s enduring untreated pain. They tested a checklist for patients on mechanical ventilation, making sure, for instance, that doctors prescribed antacid medication to prevent stomach ulcers. The list included a check that the head of each patient’s bed was propped up at least thirty degrees to stop oral secretions from going into the windpipe. The proportion of patients not receiving the recommended care dropped from 70 percent to 4 percent, the occurrence of pneumonias fell by a quarter, and twenty-one fewer patients died than in the previous year.

I am left with one resounding lesson after reading this memorable book – checks save lives.

Do better checks.

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