Checklists

According to an article in the Journal of the American Medical Association, medical

Surgery

Surgery (Photo credit: Army Medicine)

errors in what is supposedly the best healthcare system in the world kill about 250,000 people a year, making them the sixth leading cause of death in the country. Why isn’t there widespread outrage and fear over this? All I can think of is that airplanes crashing and ships catching fire kill many people all at once while hospitals kill one person at a time.

Common medical errors include things like preventable infections, operating on the wrong limb, leaving tools and sponges inside incisions, and prescribing medicines to which people are known to be allergic. A necessary solution to this, I submit, is to require the healthcare industry to embrace checklists and the philosophy that goes with them.

It is thanks to the Affordable Care Act, a.k.a. Obama care, that some action has begun to deal with such problems, the most significant so far perhaps being the mandatory use of electronic medical records for Medicare and Medicaid patients. I am now at this late juncture hearing that the medical industry has begun to embrace checklists, something commercial aviation and the armed forces, have been using for many decades.

My own experience with checklists began with submarine training in 1961 when I learned that they were a core part of a long and painful heritage of preventing mistakes. Submarines have checklists for many things including quiet running, fire, poisonous gas (mainly chlorine), and flooding, but the ones most used are for checking the “rig for dive” in each compartment. This is a list of all pertinent valves and fittings and their proper positions for making the ship safe and ready for diving, high pressure air, ship’s service air, hydraulic valves, sea water valves, sanitary valves, torpedo service valves, emergency blow ball valves, salvage valves, air flappers, and a check that debris is not present in battery compartments that could hamper air flow. They are complete lists is what they are, and their use is not optional, no matter how experienced the operator. They are mandatory. When the report is made, “the ship is rigged for dive”, doubt is absent because of checklists.

Consider this similar philosophy I came across regarding commercial aviation:

While your pilots are waiting for takeoff, it may surprise you that they’re probably doing a safety drill — what if this or that should go wrong on takeoff, which buttons would we push or steps would we take? So they go through the motions of various procedures, touching and even moving the controls. They call these touch drills, and Andy and Diane suggest that passengers do the same thing just before takeoff, perhaps buckling and unbuckling their seat belts three times. Sounds daft? “It’s muscle memory,” said Diane. “In an emergency, people panic. They think they’re in their cars, and try to release the seatbelt by pushing a button rather than lifting a flap.”

Indeed, as the final report of the U.S. National Transportation Safety Board noted following the crash of US Airways flight 405, which landed in the water after takeoff from New York’s LaGuardia Airport, “Some passengers tried to move from their seats while their seatbelts were still buckled, and other passengers had difficulty locating and releasing their seatbelt buckles because of disorientation.”

IMG_0017The point here is that intelligence and skill are incomplete without training and practice, and for those you need standard procedures.

When Mollie and I went on a cruise vacation last month, I used a checklist to get ready. While it might seem simple common sense, perhaps you, dear reader, might see value to the concept, even for so mundane a purpose. The concept has served us well over the years and I refine it for each trip.

TRAVEL CHECK LIST

Actions

  • Hold mail, newspapers
  • Schedule dog kennel
  • Gas up car
  • ATM for cash
  • Sync iPad & pedometers
  • Cancel TV news programming on DVR
  • Set lights, thermostat
  • Stove off, refrigerator shut
  • Bathroom stoppers open, toilets not running
  • Flag, bring in
  • Leave light on
  • Perishables in fridge – dispose
  • Trash – put out


To Pack

  • Hats
  • Light jackets
  • Sport coat
  • Sweaters
  • Pajama pants
  • Athletic suit
  • Swim suits, go-aheads, tennis shoes
  • Sunscreen
  • Passports
  • Cash, checkbook
  • iPad, iPods, headphones, Kindle, camera
  • Cell phone, fitbits 
  • Chargers for the above 2 lines, plus multiple outlet plug
  • Binoculars
  • Sunglasses
  • Travel alarm clock
  • Back scratcher
  • Medicine, his & hers
  • NuSalt
  • Eye drops
  • Cruise boarding passes
  • Flight schedule
  • Back rest pillow for plane
  • Tape (clear) for luggage tags, etc. (has surprisingly many uses)
  • Sense of humor

 

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About Jim Wheeler

U. S. Naval Academy, BS, Engineering, 1959; Naval line officer and submariner, 1959 -1981, Commander, USN; The George Washington U., MSA, Management Eng.; Aerospace Engineer, 1981-1999; Resident Gadfly, 1999 - present. Political affiliation: Independent, tending progressive as the GOP recedes from its Eisenhower roots.
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15 Responses to Checklists

  1. jwhester says:

    I agree with your focus on checklists, Jim. But your leading paragraph includes an assumption that I think is not true. I’m not sure whether you are being facetious when you say “supposedly the best healthcare system.” We have the most expensive, but we are far from the best. According to this article there are 36 countries with better systems than ours:

    http://www.businessinsider.com/best-healthcare-systems-in-the-world-2012-6?op=1

    It is an important point because the bogus claim that America has the best system is one of the arguments made against any reform to our system.

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    • Jim Wheeler says:

      JW, I will give you a solid A grade for providing an interesting link that itself has other good links on the healthcare subject. I recommend them highly to all readers of this post. Thanks. I’m afraid I have to flunk you however on your ability to recognize sarcasm. 😀

      Like

  2. middlechildwoman says:

    As a retired secondary teacher, I LOVE lists. I often make them, then forget them but just the task of writing it down helps. Since about 1/4 of my income goes for my healthcare – ah, those genetics come into play sooner or later – I expect near perfection from my doctors. I am still having to remind my cardiovascular surgeon to share CT scan results with my primary care physician. Then I have to ask my primary care guy to share blood tests and BP readings with the surgeon. They are employed by the same hospital system which has electronic record-keeping. Does nobody communicate in our health-care world?! A bit baffling. One other thing – no socks or underwear were on your packing list which seems essential to the pragmatic mother in me. Love your technological savvy – reminds me of my father who served as a Navy pilot in WWII.

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    • Jim Wheeler says:

      @ Middlechildwoman,

      Electronic medical records are new to the system and like most huge, bureaucratic systems, the healthcare industry is, I suspect, slow to change. However, I do know that ObamaCare intends to standardize such records so they can and will be easily and routinely shared among what is now a helter-skelter patchwork of independent providers.

      Despite my belief in checklists there are some things so obvious, like underwear, socks, shirts, belts, ties, a dark suit and black shoes that I didn’t feel it necessary to list. Those are the things everyone thinks of when packing, no? The checklist is designed to catch what I might otherwise miss. But they aren’t foolproof, either. I took a bottle of pills and checked off meds only to find when we got to Florida that the bottle was low and was short two pills, my new supply resting comfortably in my bathroom at home. I had to take some at 36 hour intervals instead of 24. 🙄 I’m not going to add pill-counting to my checklist though – that detail is now firmly etched in my brain, and besides, Mollie won’t let me forget a second time. 🙂

      Thanks, Middle, for your kind comments.

      Like

  3. I also write checklists when we’re traveling. I put it up on a google doc, so that we can access it while away, because it also includes the “return home” checklist. I have mine fine-tuned as to the day — such as two days ahead, stop newspaper, and “do this” the day before (water plants, return library books, clean refrigerator, etc.), and on the morning of departure, I have unplug coffeepot, unplug toaster, thermostat on 55 … Lists! Lists! Yes, even physicians in emergency rooms are well served by lists.

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  4. ansonburlingame says:

    To all,

    Having been both a submariner and a nuclear operator and supervisor, I know full well the value of “checklists”. Actually what Jim is speaking of is more than just a single checklist for a single person however. He is talking about “two man control”. One man uses a checklist to “rig a compartment for dive” and another man, separately and independently and of a more senior rank does the same thing. Two people, independently and welll trained and qualified to do so, rig each compartment for “dive” or line up a nuclear system to perform certain operations. It for sure MITIGATES many errors. It is also time consuming and thus expensive (but for sure worth the expense in my view)

    However, even with such controls, many times mistakes are made in “rigging for dive” and the mistake is only found when “water gets into the people tank” or lesser problems (like a vent valve fails to open, etc.) It does not happen “all the time” but happen it does and danger exists. NEVER did I “assume” the ship could submerge safely simply because it was reported to me that the ship was “rigged for dive”, as only an example, and EVERYTIME we “pulled the plug” I held in the back of my mind “what if” ……….

    This is a longwinded explanation of what, in my view, is the ULTIMATE “safety control” of dangerous tasks. Simply stated it is RESPONSIBILITY AND ACCOUNTABILITY levied at the “highest level”. Never as the CO of a submarine did I actually rig anything for dive. But had the ship suffered major damage upon submerging, I and I alone would have been ultimately responsible.

    Now move forward and explain to me how many “Chief Surgeons” in a hospital have ever been fired or sued successfully when a “surgeon” cut off the wrong limb, or left something behind in a body cavity? Actually, other than an insurance company paying out a lot of money, how many surgeons have actually lost their liscences to practice medicine as a result of such errors.

    I will make this simple point in terms of submarining. Jim, as a junior officer KNEW that if his compartment in fact was improperly “rigged for dive” and he had signed the checklist that it was properly rigged, well that would have been a “career threatening” mistake for sure. At a minimum his ass would have been “kicked” to kingdom come and his fitness report would have certainly been “less than” he would have hoped for, with career consequences for only one mistake, failing to check shut a valve properly that resulted in potential grave consequences.

    Now show me that we have such responsibility and accountability in our “best” medical profession or how any government regulation can make much of a difference when such mistakes happen??

    I leave it with the very old Rickover observation. When something goes wrong, if you cannot hold someone accountable (and DO IT, hold them accountable) then you have never had anyone really responsible for events that happen, bad or good.

    Anson

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  5. PiedType says:

    I’ve always made lists. For everything imaginable. Just the act of making the list helps you to remember it — the visual stimulation, the muscle memory from writing it (assuming you don’t use a computer). Granted, more lists probably need to be employed in hospitals, but certainly some always have been. Lists like what equipment and which instruments to have available for the surgeon. When I went for my eye surgery, several different people in the course of their duties verified which eye was to be operated on. The primary nurse looked at my armband, looked at my chart, asked me which eye was to be done, confirmed with the chart again, then marked my forehead above the designated eye. It was very systematic.

    There’s lots of room for improvement, but I was reminded by a comment above — doctors are human; they are fallible. They are not and never will be perfect. Mistakes will happen despite all precautions. So do you end a doctor’s career over one mistake? Granted, it might even have cost someone their life. But do you end a career over a human error? That could be a very sticky wicket indeed.

    Bottom line, yes. More checklists would definitely help.

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    • Jim Wheeler says:

      You said,

      “Mistakes will happen despite all precautions. So do you end a doctor’s career over one mistake? Granted, it might even have cost someone their life. But do you end a career over a human error? That could be a very sticky wicket indeed.”

      Indeed. I believe that doctors, and especially surgeons, are likely to have an overabundance of self-confidence that is bolstered by periods of success, and that easily leads to overconfidence. In the Navy, singular mistakes have big consequences. Naval officers know that if the ship goes aground or has a collision, those involved, the Captain, and possibly the Navigator and the Officer of the Deck, will likely loose their careers regardless of the circumstances. It’s tough accountability, but it works. I think accountability for doctors is, as you imply, much less. Since the medical-error rate is so scandalous, I personally would rather be operated on by a surgeon who knew his career was on the line if his team left a sponge in me.

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      • PiedType says:

        I’m sure they are all aware of the consequences of mistakes. And if not, their patients’ lawyers will remind them.

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        • Jim Wheeler says:

          It’s easy to think that takes care of the problem, but it doesn’t. The mistakes are very few for any doctor, but when they happen, doctors rely on malpractice insurance. That doesn’t help the damaged patients who number more than car accident victims. The rational solution is to stop relying on individual doctors as if they’re gods and use a systems approach like commercial aviation and the military do. IMO.

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          • PiedType says:

            My point is that even the most meticulous checklist cannot prevent the slip of a scalpel, an accidental nick of adjoining tissue, a misidentification of a tiny vein, etc. Doctors will always be imperfect humans. As important as checklists are — and I agree they should be employed in every possible situation — none will turn a human doctor into an infallible god.

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  6. Exactly

    You might listen to commercial airline pilot Martin Bromiley – he has made it his mission to introduce human factors into the UK health system after the death of his wife (google ‘just a routine operation’)

    What is particularly interesting are his insights into system error – even though two very senior anaesthetists failed to adequately manage his wife’s case, Bromiley did NOT want them castigated. Rather, he made sure they return to work and continued to spread the word about systems failures and error….and to incorporate lessons from aviation such as checklists and human factor training.

    It’s fascinating.

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