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Saving 28,000 Lives a Year
The New Yorker is running a piece by Atul Gawande that starts by describing the everyday miracles that can be achieved in a modern medical intensive care unit, and ends by making a case for a simple and inexpensive way to save 28,000 lives per year in US ICUs, at a one-time cost of a few million dollars. This medical miracle is the checklist. Gawande details how modern medicine has spiraled into complexity beyond any person's ability to track — and nowhere more so than in the ICU. "A decade ago, Israeli scientists published a study in which engineers observed patient care in ICUs for twenty-four-hour stretches. They found that the average patient required a hundred and seventy-eight individual actions per day, ranging from administering a drug to suctioning the lungs, and every one of them posed risks. Remarkably, the nurses and doctors were observed to make an error in just one per cent of these actions — but that still amounted to an average of two errors a day with every patient. Intensive care succeeds only when we hold the odds of doing harm low enough for the odds of doing good to prevail. This is hard." The article goes on to profile a doctor named Peter Pronovost, who has extensively studied the ability of the simplest of complexity tamers — the checklist — to save lives in the ICU setting. Pronovost oversaw the introduction of checklists in the ICUs in hospitals across Michigan, and the result was a thousand lives saved in a year. That would translate to 28,000 per year if scaled nationwide, and Pronovost estimates the cost of doing that at $3 million.
JUST DO IT!
Seven Days with Ubuntu Unity
They reflexively cry out against 'cookbook' medicine and 'socialized medicine' while ignoring sound scientific advice.
We really do need an attitude change here in the same way that Detroit needs an attitude change. (Throw the dinosaurs out.)
I don't read your sig. Why are you reading mine?
The medical field has finally taken a hint from the success of the underpants gnomes:
...
Step 1) Create checklist
Step 2)
Step 3) Life Saved!
I don't see how it's anywhere near a "one-time" cost. What if the checklist needs to change? Who controls it? Who approves changes? Are we printing them? Wouldn't HIPAA regulations alone increase the impact caused by adding a new sort of record keeping? Think of the carbon impact this would have, more waste for landfills (or if you're dark, more people consuming and creating waste because they didn't die).
They use checklists for everything, and flying a plane is much less dangerous than operating on someone in an ICU.
Don't they already have some kinds of checklists for "make sure we don't leave any sponges or scalpels in the patient."
If I have nothing to hide, don't search me
then you must realize that that's at least 14,000 new homes destroying natural habitat. 28,000 extra people consuming resources and having too many kids.
Let them go. Save everybody and you damn everybody.
If a fix for a problem isn't extremely expensive and convoluted with contracts for politicians friends, there will likely be no mandate for it, so short of lawsuits that start quoting these findings, probably nothing will happen, because there will be no coordination, in which case it will cost considerably more than $3M nationally, and regions will not be able to justify it.
I say this extremely long statement with a bit of experience.
I created an application for exactly this purpose to be used by a major hospital in the UK. My point is that it was just for the one hospital. There was no standardisation across the industry. The company I worked for at the time made websites and intranets for lots of hospitals, all basically the same thing, and each one costed and sold entirely separately. The hospital system could have paid 5 times the cost of one site and gotten hundreds, but that just wasn't how they did things.
I'm gonna need a spec.
At least in America, people's ecconomic status in life is in constant change. Someone rich or middle class can be poor while someone poor instantly changes to middle class simply by being employeed with the right company.
Anyone who has been stuck eating Ramen for months at a time please raise your hand. God knows how many time's I've been in a funk. Today, I enjoy making around 60k a year.
The point I'm trying to make is this. We need to stop looking at people being rich or poor and see them for who they are. Human beings.
Life is not for the lazy.
Pronovost oversaw the introduction of checklists in the ICUs in hospitals across Michigan, and the result was a thousand lives saved in a year. That would translate to 28,000 per year if scaled nationwide
I know that the US medical system is in tatters but surely you have more than 28 large hospitals nationwide???
These posts express my own personal views, not those of my employer
"The article goes on to profile a doctor named Peter Pronovost, who has extensively studied the ability of the simplest of complexity tamers â" the checklist â" to save lives in the ICU setting."
1) Is patient alive? No check.
2) Search wallet. Check.
Shai Schticks:"You don't make peace with friends, you make peace with enemies"
So the checklist reduced infection rates. But then, how many lives were lost for other reasons because medical staff wasted time on these checklists, while nurses enjoyed obstructing physicians?
A few years ago, people were absolutely sure that millions of lives could be saved by having AEDs everywhere. How many lives are being lost by amateur do-gooders who unnecessarily electrocute people who are not having heart attacks? Plenty of medical problems can appear like heart attacks to the untrained eye.
Imagine if the brakes on your car failed just 1% of the time. For every 100 times you brake 1 time you'd just keep going. How many times do you brake on an average 1 hour trip? Sometimes for mission critical systems even 99.999% isn't good enough. It's not just mission critical systems though. What about computers. If they made errors once in 10000, with several billion cycles per second, they'd be unusable.
Anyway if each patient requires 178 actions then 1% means every patient has between 1 and 2 mistakes made for them per day. I presume some of these actions are trivial otherwise I'd be amazed if anyone survived.
These posts express my own personal views, not those of my employer
I've got it on a checklist....
er, somewhere....
Now, where did I put that thing.
Sometimes boldness is in fashion. Sometimes only the brave will be bold.
No you jackass! It's called getting hired and then being laid off from work. Last I checked, it's fairly common in the IT world.
BTW, why are you trolling? Did someone hi-jack your account or something?
Life is not for the lazy.
Spoken like a true middle-class wealthy white kid who's never worked a day in his life. Do you seriously think that only rich college kids have to eat crap food just to survive sometimes? Something else you gotta realize, QuantumG, is that just because someone's poor, doesn't mean they always have to be poor. Anyone can work harder, better, smarter, and get better in life.
"Don't they already have some kinds of checklists for "make sure we don't leave any sponges or scalpels in the patient.""
Corsec67, I'm sorry to tell you but we left a nurse inside you.
Shai Schticks:"You don't make peace with friends, you make peace with enemies"
Now that you're on the 60k or whatever, I recommend saving. :)
BTW, why are you trolling? Did someone hi-jack your account or something?
It's either this, or go back to playing Eve Online. I'm not that bored yet.
How we know is more important than what we know.
Hehe, you don't know shit about me dude. I only went to university because I live in a socialist paradise (Australia). In the USA I'd be mopping floors. The land of opportunity is anything but.
How we know is more important than what we know.
Pilots come and give talks in hospitals about how checklists significantly reduced air crashes in the USA, which it has.
I saw this presentation at my hospital, but I'm not exactly sure if it is applicable it medicine.
..........FULL STOP.
So based on the math, the cost of a person's life is worth $107.
$3,000,000/28,000
Thats assuming that the $3,000,000 is required each year.
Sounds like another reason to be pissed at the medical industry if they don't do it now that they're aware. Makes me curious if the cost of medical malpractice suits are higher than this $3,000,000.
In Atul Gawande's book "Better: A Surgeon's Notes on Performance", chapter 2, "The Mop Up", he discusses the program to eliminate polio in India.
Checklists certainly aren't just for medicine, they work great in IT too. As a system integrator / contractor, I've found that lots of IT people have a somewhat.. haphazard approach to day-to-day tasks like building servers or provisioning users. This inevitably leads to mistakes and forgotten steps, which then results in angry users and system failures. Of course, the same IT people then apply the fix with the same lax methodology, and the result is yet another failure, and an even angrier user. I've seen this cycle repeat as often as 3 or 4 times, until managers get involved, and fingers are pointed. It's very unpleasant for everyone after that.
My method is trivially simple, and required nothing other than a text editor, even Notepad works fine, but a more robust editor is even better.
I call it: "Pete's Patented TODO List System". (Patent not pending).
Simply open a new file, and create a line for every single step of the task you're about to do, even if it's blindingly obvious. Prefix each step with a pair of square braces as a placeholder for a check box. E.g.:
=== BUILD SERVER === ...
[o] Back up existing data from drives
[.] Patch BIOS to latest version
[ ] Reset BIOS settings to platform defaults
[ ] Boot installer from \\foo\bar\...
[ ] Configure drives
[ ] Clean existing RAID
[ ] Create mirror pair
[ ] Configure block size to 64KB
Once you have the file, as you build the server, you tick steps off by filling in the checkboxes. E.g.:
[ ] Not done
[.] Started / partially done
[o] Done.
[!] Issue / problem
[?] May not need doing / optional / ask
[-] Cancelled / no need.
So you ask.. why is "Pete's Patented TODO List System" so awesome? Because it works, it's free, and it's flexible. I found my error rate plummeted, and I could then email the list to someone else, and they could reproduce a successful procedure flawlessly by simply following the steps. There's actually a whole range of reasons why a text-based TODO list system is the best for IT:
- It can be cut & pasted back and forth between local and remote systems.
- After a task is complete, you can email it to managers or coworkers as a "record of activity".
- Others can read your list without requiring a client such as Microsoft Project.
- Any idiot can use a text editor without special training. Quickly reorganising the structure and order of a complex multi-step task in dedicated Project management software takes effort, and may cumbersome.
- It's easy to cut & paste parameters, values, scripts and command in and out of the TODO file.
- You can reset a file to "blank" by doing this Regex search and replace: \[.\] => [ ]
- Did I mention it's free? (I do accept PayPal donations, however)
In general, TODO lists rock, especially in environments where scripting everything is not practical. For example, if you build multiple servers in parallel, simply open two Notepad windows, and track the progress of each server. If you're interrupted by a phone call or a user, you WILL forget what exactly you have or haven't done, and that's when fuckups occur.
Not to mention that most IT people just don't do "all the steps", which is one of the main points in the article. For example, do you, or the people working with you, do ALL of the following when configuring a server:
- Wipe all of the existing configuration, including BIOS settings?
- Run a memory check?
- Set the date and time in the BIOS?
- Patch up all components to the correct / latest levels, including obscure things like the network card firmware?
- Install, configure, and TEST the antivirus, backup, and monitoring modules? Did you run a test backup AND a test restore?
- Verify that every step worked?
If the answer is no to ANY of those, you or your people are fucking up on a regular basis, whether you know it or not. I've lost count of the number of times I've seen "enterprise clusters" where 2 of the 5 nodes have a different date & time. It's a trivial thing, yes, but MY GOD DOES IT BREAK THINGS if you forget.
it seems like a good investment.
Quick! Somebody call Barack Obama!
Funny thing about mopping floors... The money you earn can be used to pay for college. It's called earning a living. With a few exceptions, sustained poverty is a self-inflicted condition in the U.S.
This is not a troll, this is someone who witnessed his parents bust their asses from dirt-poor up to lower middle-class. Because of their example, I've worked my way from lower middle-class to upper middle-class. I have every confidence that my children will surpass my standard of living and continue the path upward.
Unless you have some mental illness or deficiency that prevents you from holding a solid job, your financial future is your own to make (or not).
Your "socialist paradise" paid for your education by sending the bill to people who actually earn their keep.
Umm... I don't know if the editor noticed, but this article was published over a year ago.
How is this news?
Your "socialist paradise" paid for your education by sending the bill to people who actually earn their keep.
No actually. They make you pay back every cent, and then some.
It just guarantees that everyone gets the same opportunities, not just the kids with parents who can afford to send them.
How we know is more important than what we know.
People can be quite resistant to things like checklists, thinking they know it already. Checklists will help with procedures that are rare enough that people will know to revert to the checklist, but I bet relatively common activities will still be subject to errors.
dom
It's not as glamorous as discovering a cure for some new disease, but it works great.
Notice the other things mentioned in the New Yorker article:
In fact, the most important part of the whole article is in these paragraph:
Ignore QuantumG, he's a jackass and a troll, things available in plentiful quantities both here in Australia and over there in the US.
Not to mention the fact that all it takes is a single misstep to fuck you up. Believe me I know. When I was a kid we went from rolling in dough to 3 years on welfare nearly starving. Why? Because my dad who was making damn good money at the time as a special job truck driver(because he could make a semi dance and get it into places that people would swear a truck wouldn't fit) and went to help a fellow driver who had got his load hung up. After he got it loose he went up top to check on the damage and a piece of the top crumpled under him and launched him head first off the roof onto concrete. The medical bills for putting his skull back together, plus the ICU bills quickly blew through the insurance and savings and due to the damage he was not able to work for nearly 3 years.
That is why every chance I get I try to help out those that don't have as much as me, and spend a decent chunk of my free time talking SMBs out of and raiding junk shops for PCs that I then rebuild and give to those that don't have one. Knowing that I can use my time and knowledge to make life a little better for a single mom, a kid needing a decent machine to do his homework on, or a small church that uses their donations to help the poor not only gives me a good feeling but makes their lives a little easier and at the same time saves a working PC from becoming just another pile of e-waste in a landfill. For example I helped set up a little network of donated PCs for a battered womens shelter that uses them to teach office skills.
So in this Xmas season don't think the only way you have to help is by throwing cash in a charities coffers, there are many ways that someone who knows IT can make someone's life a little easier. Believe me there are plenty of groups out there doing good work whose computers and/or networks are about to fall apart. A little of your time and some donated gear can make a big difference.
ACs don't waste your time replying, your posts are never seen by me.
2) Follow the checklist and eliminate the 1% error that kills 28,000 patients a day.
I know this is /. and you're not expected to read the article. But could you at least read the summary?
Weaselmancer
rediculous.
But if it isn't being done yet, a reminder won't do any harm!
The most significant thing I find (going from a year-old memory) is that they had to get the bean-counters to increase the amounts of disinfectant and protection sheets they bought, since these amounts increased VERY significantly when check-lists were used!
Each time the hand off was done mostly verbal, always asking the same basic questions time and again, and if they forgot to ask a question of the outgoing staff, they would interrogate my wife who was heavily sedated and mostly unaware of her surroundings. Each time I had to step in and clarify. We were lucky she had a seasoned doctor, and I personally witnessed him rip a few new a$$holes.
I had the same thing happen when I slipped a disk in my lower back and required an ambulance. Although in excruciating pain, I had to recite my history and present circumstances to each staff member I came in contact with. It was like watching the old telephone game, where the original spoken message to the first person rarely matches by the time it makes it to the last person.
If they just had a way to not only capture the patient background and case history but easily convey it to next nurse or doctor, I would bet it would reduce plenty of mistakes. Currently, the details are written on forms, then entered into computers, only to be requested again from the patient by the doctor or next specialist or consultant. It would seem they either don't have easy or convenient access to the data on the computer or the doctors don't have the time to read the narrative. Perhaps some form of speech synthesis would work. The doctor could step into the room, press a button and get the playback or some form of timeline with the ability to drill down into details.
On a final note, if you ever have someone you know in the hospital, never leave them alone. You should make every effort to oversee their care and babysit the doctors and nurses. I don't know if our case was indicative, but when I saw my wife, who was hanging on to life in the ICU, sit up and scream because the nurse attempted to reuse an expired IV point, it got my attention! Not two minutes early I just got done telling her that the reason they moved her from immediate care to intensive care was because they could no longer medicate her through her IVs since they had all expired.
Fortunately she pulled through and has little memory of the hospital events. By the way, I almost lost her and it was just a kidney stone that was stuck. Don't ever buy the line "oh, they are painful but they will just pass". If the stone backs up the kidney too long, it can create an infection, which will immediately pass into the bloodstream. The rest is pretty fast and scary.
Imagine if the brakes on your car failed just 1% of the time.
This isn't a correct comparison. They made errors 1% of the time. An error becomes a failure only when it is allowed to cascade through the system.
We had a similar presentation at work (from one of our grizzled engineers who is also an amateur pilot). A commercial flight encounters, on average, two errors. However, this doesn't mean your average flight crashes and burns; these errors are corrected through redundancy. For example, this is why pilots repeat the instructions given to them by air traffic control before carrying them out. ("Set altitute to nineteen thousand" is very different than "set altitute to nine thousand," though they can sound alike!)
I presume some of these actions are trivial otherwise I'd be amazed if anyone survived.
Some are trivial: Mr. Smith got his dinner switched with Ms. Doe. Some are corrected: Dr. Hathaway asked Nurse Jones how Mr. Smith is responding to his meds, which Jones had forgotten to administer but promptly remedied. And the rest... yeah, that's when bad things happen.
It can be hard to institute these sorts of checklists onto an existing system, though. People often take it as an insult to their skills and intelligence ("Yes, I know how to upgrade a server. I've done it a thousand times." "Yes, I know how to perform bypass surgery. I've done it a thousand times."). The trick is finding a way to get people to want to do it.
God bless you. You're a better man than I.
He assigned an extra nurse to make sure that the others followed the checklist. At first the nurse was just an observer, but when the trial period results revealed serious omissions in some incredibly high percentage of cases (ISTR 33%), the nurses were authorized to intervene and tell the doctor to respect the procedure.
If you actually check off the items on the list and not just look at them, you don't need your memory to tell you whether you've done them or not, you can just look at the check marks.
The other half of the equation is taking the check list seriously in the first place. If you do that, then you WILL read and comprehend the questions.
Awesome!!!
I have my entire server provisioning procedure in a single shell script. I run the installer, update everything, and then run my "magic" shell script. When it's done, the system is ready for action.
I think of the shell script as a TODO list, but it's bash that's doing the work instead of me.
I wouldn't have it any other way. Human memory is too fallible, and even written instructions are open to interpretation.
What's up? The article this piece references was published in the Dec 7, 2007 edition of the New Yorker.
It's a great article and I enjoy the discussion of it, anytime -- but this kind of violates my expectations of Slashdot content and that's problematic.
Namely, being that once a check-list is created, after a while, one gets to the point where it's only the check-list that matters. Not on the check-list, doesn't happen. In other words, it allows people to get lazy and not pay attention. So, there will likely be errors produced from that negating the lives saved with nothing gained, but at the same time, a grand potential lose. The lose being a mentality of brainlessness in the ICU.
One must weight also weigh the practical consequences of such things that would have benefits against those benefits as well. We need to see a net gain first. Especially before widespread adoption.
I'm not going to say it's not like that. But it's certainly less true than it used to be, even ten or fifteen years ago.
These days the middle class is getting squeezed seven ways to Sunday. So apart from being good looking, a good [enough] singer or expert at chasing or hitting a ball around, the routes upward are becoming blocked. And all the time the haves - those who were born with money and connections - are entrenching their position even more.
The best decision a kid can make is to choose wealthy parents.
Confucius say, "Find worm in apple - bad. Find half a worm - worse."
First time that my girlfriend shall receive a NEJM (New England Journal of Medicine) that had an article on /.
She's a recent subscriber to the NEJM and her day (and night) work, as a doctor working in an ICU, is a lot about placing catheter.
This is going to make for an interesting discussion tonight when she comes back :)
As an RN, I can say that paperwork has gotten totally out of control. Most of my time is spent documenting stuff, rather then simply spending time with the patients. IMO what improves patient care/quality is spending more time with patients. I would be very weary of any additional mandatory documentation, especially if it is in paper form.
I would be OK with the checklist idea if it took the place of other paperwork instead of being a new item. They could even put the checklist into a PDA application, which could then automatically document what was done in the chart. We already use PDAs at my hospital for meds and other things.
Submitter/kdawson should have kept going with the summary...
FTFJA:
Important reductions in morbidity and health care costs could be achieved if the intervention to reduce catheter-related bloodstream infections could be introduced successfully nationwide or worldwide. Given the results of the study, many of the estimated 80,000 infections, up to 28,000 deaths, and $2.3 billion in costs attributed to these infections annually in the United States could be reduced.
Spend $3 million to save $2.3 billion, JUST on catheter-related bloodstream infections in the US each year.
Stunning.
around 25% of the patients that die in western hospitals. It's ranked 3 on causes of patient death in hospitals - right after cancer and cardiovascular disease which together account for 50% of deaths. Fatal errors in treatment have been proven to drop to 8% in hospitals using computer technology for managing patients.
I'm a little stunned that saving Americans with simple rudimentary organizational tactics for over $1000 each is considered a bargain while many countries cannot afford to vaccinate their children or an effective defense strategy against HIV.
War as we knew it was obsolete
Nothing could beat complete denial
- Emily Haines
Your "socialist paradise" paid for your education by sending the bill to people who actually earn their keep.
Yeah, it came to me after I finished my degree. We basically run our student loans as part of the taxation system. It's called investing in our people.
Anyone who has been stuck eating Ramen for months at a time please raise your hand.
Whaddya mean "stuck", Kimosabe? Ramen noodles are fuckin' delicious! Pop some peas and corn in there and you're ready to rock! :D
We need money to fight the war on terror, because terrorists are threatening American lives.
They're called ordersets. I worked for a company that sold subscriptions to them and had software for authoring your own. Subscriptions started at $1 million/year, three year minimum contract. Not out of the question for a large metro hospital, but may be out of reach for the budgets of a smaller county hospital... Last I heard, the company was tanking.
... so technically, the "New Yorker" isn't "running" it anymore ... ;-)
"I love my job, but I hate talking to people like you" (Freddie Mercury)
That depends on where you are in the US. Two states that I know of(Georgia and Louisiana) provide free tuition to all students with a certain GPA and test scores. In Louisiana the test score requirement is lower than the admissions requirement at the larger Universities, so pretty much everyone at LSU gets free tuition.
The Space Shuttle Flight Software team uses checklists extensively for their daily work. They even have a checklist to ensure they've included the appropriate checklists for review of their work. When lives are impacted by your work, you own it to those lives to use checklists. They are required to sign off with their full signature on each checklist completed. When I worked there, I took signing my name VERY SERIOUSLY. I only signed when I'd performed the work and believed I was 100% correct. This is also part of the reason why NASA software often costs much more than hacked together software.
Doctors - take note. You make mistakes. A checklist can easily reduce the number. Do it.
I recall reading a similar article, where a hospital used six sigma techniques to develop similar checklists. The program was shut down because the FDA claimed it's approval was needed before the checklists could be implemented.
The changes need to be made at the FDA, then health care will improve.
One of our competitors trademarked the term "hypothesis". From now on, we will call them "boneheaded ideas".
Oddly enough, I had the same experience in the USA. You certainly can get an education even if you don't live in a "socialist paradise".
Slow down, cowboy! It has been 4 hours since you last posted. You must wait another few hours.
Apparently they got in a bit of trouble over this - not for instituting the checklists, but for having the gall to track results to see how effective they were. Because of that, it basically becomes an experiment and you have to get all sorts of permissions.
A bit more detail in this NYTimes editorial
And some commentary from the University of Houston Law Center: here
Note that all of this is actually a bit dated - the original New Yorker article was from December, 2007 and the followups that I saw were from January, 2008. I don't know what's happened with it since then; I suspect that checklists have been implemented in some hospitals but that nobody is sharing results.
fencepost
just a little off
There are several initiatives that will a bigger impact
and Pronovost estimates the cost of doing that at $3 million.
Right there is your problem. If it were $3 billion Congress would readily do the appropriations and call a press conference where even the guys who opposed the bill would take credit for spending large amounts of money in "saving lives".
But 3 million dollars? Not a chance in hell that it will ever be supported.
Oh, No... Patient X is going into respiratory arrest, nurse prep the de-fib stat.. I need a crash cart...
Where is that damn checklist? oh there it is on the counter, lets see.. check vitals.. observe patients breathing - is it labored? if yes go to section 1A, if no, proceed to step 2.....
shit, doctor - we lost him....
thats why checklists are bad, and why doctors are paid obscene salaries...
Actually, hospital personnel are supposed to ask for your medical history multiple times. IANA(medical professional), but I read that asking multiple times is intended to make sure the information is as accurate as possible. If I remember correctly (and I can't find the link, sorry), at least one study found a noticeable difference in what patients disclosed of their medical history over the course of a stay in a hospital. Oftentimes, patients would either intentionally cover up some information at first (not mentioning an STD, for example, because of embarrassment) or simply forget to mention something (e.g., forgetting to mention a medication or accidentally giving the wrong dosage).
This is not to say that repeatedly asking a patient under a haze of drugs or pain is the best approach, but there can be valid concerns behind it.
What, checklists? Will never happen. Hospitals are run by and for the convenience of doctors, not by patients. No doctor is going to agree to be held to a checklist, where deviation from it may be cause for a lawsuit. Circumstances and patients vary widely-- there's no way a checklist can have the right steps for every situation. Especially in the emergency room where there is always a time lag between what has to be done and what is known.
The "study" is fraught with the "western Electric study" fallacy-- anytime you pay attention to a group of people, they're going to change their behavior. They might just as well have found that putting a bowl of M & M's on the nurses desk reduced errors.
Having the opportunity to routinely care for my patients in the ICU, I understand the authors perspective and ideas. Medicine cannot be directly linked to aviation from a safety perspective, although it is commonly done. An aircraft with a oil leak found on preflight is grounded. A similar patient is taken to the operating room to undergo a life saving operation. Action is dictated by pathology, not the other way around. It is the understanding of human physiology that allows life saving decisions to be made, not a checklist of procedures. Having also been an officer in the military and experiencing battle, its procedures and guidelines are more closely related and commonly instituted (Morbidity and Mortality Conferences/After Action Reviews etc). It is often the variable nature of battles and war that is a closer corollary for a sick patient than the controlled environment of an aircraft hangar. In addition, it is the team approach in medicine that saves lives rather than the decisions of the sole pilot. Often, lives are saved by "looking outside the box" and finding a pathological problem that was not appreciated prior. It is the common practice of non-clinical professionals to implement policies for "life saving" from a distance of their desk and computer screen and then use data collection to justify their presence. Do I use checklists in my daily operations? Sure. There is a time a place for such tools. I can tell you from experience, it should not be instituted as broad as this article would infer.
Um, hello? Nurses are professionals who need critical thinking skills and advanced training. They have many care duties that they are trained to do and without good nursing services, the health of the patient suffers. Ask anyone who has been in a hospital for an extended period of time--the patient suffers without good nursing care! Even CNA's, who have much less training than a RN or advanced practice nurse need good clinical practice skills to help patients get healthy.
I actually write software that does this. However, this is not as simple as it sounds. While the checklist for a pilot (and I am one) is very straight forward, the "checklist", or carepath or treatment pathway is not. There are a myriad of factors that determine what comes next and it is not always obvious. There are some simple things, but the fact is, the hospitals already have checklists or protocols for those items. In 10 years we have managed to complete the "check list" for 2 types of patients, Strokes and Heart Failure. Both are extreamly similar as they are both circulatory diseases. The software is easy. The carepath is exceptionally complicated. The treatment pathway, and thus the checklist, is very different if the patient is young or old, male or female, how quickly the patient is brought in for treatment. For example if a stroke is less than 4 hrs old the treatment is very different than a 7 hr old stroke. Not to mention the difference in the stroke itself. So while a "checklist" sounds like a great idea, the idea is not new. Some of us have been working on it for a while. But the reasearch that needs to go into the checklists is 99% of the cost of our development.
I am not a medical doctor. But my experience with Electronic Health Record (EHR) software tells me that the costs of implementing this are grossly underestimated. The reason? Training. Any time you introduce a new process into a medical environment there's an immense amount of training costs that occur. In installing EHR software (which enables electronic checklists) the cost is dominated by training expenses. I can't imagine making this kind of procedural change (even though seemingly simple) without significant education. Even if it it's only a few hours per medical professional the costs will be much higher than the estimates.
That's not to say these ideas shouldn't be implemented. They should - along with an EHR. EHR's have been shown to save lives. Checklists are easy to implement in EHRs.
But don't expect the costs to be anywhere near as low as Pronovost estimates.
Larry
Medical miracle?
Miracle by definition means something supernatural. If it can be attributed to science/physics, it is not a miracle. It's medicine then.
This is an article that strikes dead center to my job. I currently work in the Patient Safety Center for the US Army. I collect and help analyze patient safety events that happen when a person falls, a doctor operates on the wrong limb (or wrong person), or someone dies due to an error.
I want to say a few things.
1. The average person would be surprised at how often errors are made by doctors, nurses, and when getting your prescription medicine (please check your pills!!!) both in the military and civilian world of medicine. I was in denial at how many preventable events happen each and every year. If you even think something is wrong when you get medical care, please INSIST that they stop and look more carefully at the situation. Trust your gut.
2. This is today a culture problem. It is true -- a simple checklist will help things tremendously. Marking your surgery sites with the patient will help prevent wrong-site surgeries. Double-checking identifications will help prevent wrong-patient errors. But the main problem is that many doctors have an ego and don't want to use checklists, and they don't want to hear from a lowly nurse. They think they don't need lists.
This is where things have GOT to change. The airline industry has gone through this same thing culturally and logistically. Any staff member can stop a plane (even a flight attendant). And it didn't happen overnight, but pilots finally realized they needed a checklist.
There also has to be a culture of not punishing the person who made the mistake. Currently, if a nurse makes a mistake, they try to fire the nurse. Nevermind that the process itself lends itself to a certain error rate.
In my Patient Safety office, we are trying to correct some of these problems and change the culture from within. It is very slow and time-consuming, and there are many people who are in the way. But we are trying!
"They said I probly shouldn't fly with just one eye," "I am Bender. Please insert girder."
That's actually what's supposed to happen. In fact often when I interview a patient after the nurse or paramedic, newer details come out. Then if I admit you and you talk to the hospitalist, even more details emerge. I can't count the times that the nurse asked the patient if they had allergies to any medicines and the patient says none. Then I ask and the answer changes to 'oh yeah, when I was in the hospital for pneumonia they gave me an antibiotic and I got a bad rash and my lips swelled up...'
Though I often encounter people with the complaint you have: I already told the nurse, ask her or better yet I talked to my doctor on the phone about it, so look in the computer. That is about as useful as a wet kleenex and will actually delay things even more because I won't simply ask the nurse or look in the computer. I always do look at that data, but I don't base my care on it. In fact, you wouldn't want me to.
Actually it perpetuates them and numerous studies have demonstrated this. If you have an electronic medical record, instead of getting their own history from the patient people tend to cut and past whats already in the EMR. So that notation of the nurse that the patient has no allergies is entered by the doctor instead of asking themselves and getting the different answer.
Um, they do pass most of the time. I've passed over a dozen myself with nothing more than oral pain and nausea meds with lots of water. However it is correct that a small percentage of stones don't pass and either require removal or breaking the stone into smaller pieces so it passes or that are complicated by infection.
So in the ER I tell people most of the time they pass, but if you get X, Y, or Z symptom come back to the ER. Which is precisely what happened to your wife, I suspect. The problem is that some people are unable to accept diagnostic or therapeutic limitations and uncertainty. And when (inevitably if you come to the doctor enough) you are one of the 3% who don't get better with X treatment you assume that it is due to malice and/or incompetence. Then you do two things which shoot you in the foot:
1) You take a permanently adversarial attitude with people in the health care system. Instead of an appropriate level of concern that manifests as asking things like 'what is this medicine you are giving me and what does it do?' when the nurse brings in a medicine you become hypervigilant and every time the nurse gives you a tylenol (that says tylenol on the pill,) you ask to see the bottle it was from and write down the lot number, expiration date, and the nurses name in your notebook. Just a clue for you: this is going to breed contempt. If you treat the nurses like crap and imply they are malicious and/or incompetent, often your wife may get the standard of care, but she won't get the little extras that make a hospital tolerable and even improve outcomes. Fortunately for people like you, most nurses will treat you decently even if you do that because most of them entered nursing to help people and they understand that prior bad experiences can breed that kind of attitude. However providers are human and don't be surprised if they react li
Dunno about TNY "..running an article..." since the URLmakes it clear this is the article I read a year ago in the hard copy magazine.
Anyway...
Humans in general resist change, and it's certainly true that medical staff are concerned that a checklist will just mean more work for them without any benefit. Part of the problem is that, when they do forget something (say they checked a patient in but forgot to record one of 5 vital signs), it's the next person in line, be it MD or PA, who gets stuck cleaning up the mess.
Checklists need to be designed with user input (gosh!) and need to be implemented diplomatically. Transitions are always tough, but sooner or later everyone in the health care field will view them as just part of the routine.
https://app.box.com/WitthoftResume Code: https://github.com/cellocgw
A simple Windows Mobile device would be just as effective:) Just kidding.
Nurses are drowning in checklists already for patient care.
Yes there are multiple counts of gauze sponges, and instruments during any surgery, which ensures an extremely low rate of things being left inside. PTs who have things left inside are an extrememly small amount - usually in dire emergency situations, and the extrememly obese.
Nurses already have lists and lists of checklists - so many that one tends to pay less attention, and just check them off.
Your anecdotal data point is representative of how risk is being moved from organizations to individuals, and income volatility is increasing even for highly educated workers (in the U.S., of course). See "High Wire" by Gosselin for detailed statistics. When Suze Orman switched to telling people they need 1 year of income in cash for emergencies, the shift in risk, the increase in income volatility, is the "why".
Besides, saving lives for the sake of saving laws is not agood reason to do something. For example: in the USA there are over 800,00 abortions a year. If you subtract fetal, infant and child mortality rates, 720,000 of those fetuses would have lived to be 19 yrs old. We are killing the equivilent of 10 years of Vietnam Vets EVERY YEAR.
So if you want to "just do it" as one idiot exclaimed, then you should just call for an end to abortion. You'll have 720,000 additional Americans every year ... that need eduction, healthcare, socials services, and parking spaces.
I don't know if the system's broken down or is just being mis-managed but at one time, I preferred military care over civilian.
The military/VA care process is still better organized and more streamlined than the horrendous kludge of the private system, but it's also under a remarkable strain from a flood of war casualties and the rapidly-aging population of Vietnam vets. Ironically, the VA system provides better, cheaper care because it does not suffer from many of the inefficiencies of a market-based health care system-- preventive care and unified standards within a single provider make treatment much more effective and cheaper in the long run.
The official count of American soldiers seriously wounded in Afghanistan & Iraq is over 30,000, even with political pressure to keep public casualty counts as low as possible by redefinition of 'wounded' and 'injured'. As of 2006, more than 100,000 disability claims had been granted by the Veterans' Administration for service in the GWoT.
Advances in medicine, personal armor, and trauma response have enabled our soldiers to survive far more grievous wounds than imaginable at any time in the past, and our responsibility for providing appropriate and continuing care is growing with this trend. Unfortunately, it's hard to live up to our promises when the political establishment is united in their desire to sweep the consequences of war under a patriotic rug...
"We have to go forth and crush every world view that doesn't believe in tolerance and free speech." - David Brin
This is when it could be an headache... A doctor performing a heart surgery following the heart surgery checklist... suddenly notices an internal bleeding.
Doctor: Nurse please get me the internal bleeding checklist
Nurse: Yes Doc... printing it right away.
The doctor then proceeds to continue to fix the internal bleeding. Then all of a sudden notices that the lungs are behaving abnormally.
Doctor: Nurse please get me the abnormal lungs behavior checklist.
Nurse: Yes Doc... here you go.
This could go on...
Same thing in the non-code world... a list of conditions which should all be evaluated before a procedure is finished.
That only works if it is the same person asking each time, or if each person is writing it down, and comparing to the earlier answers.
If each medical professional asks for the history, and does not also consult the written record of the previous histories, then there is no benefit to asking many times, and you increase risk as different medical professionals are working with different data.
I don't know if the doctors were reading the previous histories or not.
I hate it when I make a joke and I get modded "+5 insightful". Mod the stupid comments "funny", not "insightful", pleas
One thing that bothers me about this story (and the NYT article mentioned above) is the fact that hospitals are looking for Dr. Pronovost to help them set up a program, and (presumably) the fact that he is only one person is limiting the speed of adoption.
The key lesson that checklists should teach is that instead of relying on the brilliant person doing it right, you rely on the average person to do it correctly, according to the checklist.
Each hospital in the world should read this and say "I can do that!", rather than "We need to get the world-renowned expert in checklists here to do that for us." All they need to do is in their own hospital, watch and record what they do each time. Then look at it and ask what they should have done every time. Then build a checklist based on what they should have done every time. Then use the checklist. As an optional step, they could even share the checklists with other hospitals.
The key thing about checklists is that you write down what you already know, and it just helps you not forget details when you are executing on it. You don't need the smartest person in the world to create the checklist, you just need the people you already have.
Unfortunately, this seems to be contrary to doctor's way of thinking. The successful doctor has become successful by being smarter than 99.99% of the other people in the world. And when that doctor has a problem too hard to solve, he has to work really hard to find someone smarter than he is to help. The idea that a smart doctor can solve a problem by consulting with someone who is less smart (but a bit more methodical and with more spare time to create checklists) seems contrary to medical thinking.
I hate it when I make a joke and I get modded "+5 insightful". Mod the stupid comments "funny", not "insightful", pleas