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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.
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.
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
Having been both a medic and a programmer, I can tell you that "basic proven work flow improvements" are not one-size-fits-all.
The correlation between ignorance of statistics and using "correlation is not causation" as an argument is close to 1.
In my experience with rocket engine tests, both professionally and as a hobby, I've seen checklists be invaluable tools. I've seen them catch problems that were irrelevant, ones that would have resulted in loss of data, ones that would have resulted in incorrect operation, and ones that had direct safety impacts. However, the problem you describe is very, very common. The simplest solution is quite effective, and they discuss it in the article (but fail to mention how amazingly important it is). You need the person who is responsible for reading the list and making sure each item happens to *not* be the one doing it.
In the article, the nurses follow the checklist and stop the doctors if a step gets missed. At an XCOR Aerospace rocket test, at any given time there is someone whose sole responsibility is reading the checklist (who that is may change through the day, but there always is such a person, and who it is is always clearly defined). In both cases, the person with the checklist has the authority to stop whatever is happening and correct the situation. When I test my hobby rocket motors, the test crew is much more limited (usually two or three people, compared to at least six and often many more at XCOR). As a result, the person reading the checklist is usually also doing things on it. Mistakes are more common, and it's not uncommon to set down the checklist and just do things for a while.
That separation of roles is simple, yet highly effective. Obviously it's a bit hard in a single-pilot airplane. But, in a situation where it's at all possible, it's well worth doing. There are a number of reasons it helps, but one of the simplest is important: the reader can hold the checklist binder with their thumb pointing at the last step completed, since they don't have to use that hand to actually do anything. In the medical case, you're actually making checks on a piece of paper that goes into the file, but the idea is the same.
As an aside, having the checklist be unfamiliar is a bad thing -- mistakes and confusion are much more common after a checklist change. The fix lies in how you use the checklist, not what it says. The reaction to hearing the next step on the list read needs to be "yep, I've already got the tools in my hand" or "oh, right, nearly forgot that" -- not "wait, what was that? Oh, right I was already doing that." If you do that, people will be more inclined to ignore the checklists, because they interfere with operations.
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.
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
How many of those fire extinguisher deaths are caused by *untrained* operators? I would guess all of them. You don't have untrained operators working in an ICU or at a rocket test site. The more critical the rocket test, and the more chaotic the environment, the more important checklists become. I'm sure the same is true in an ICU. The idea that checklists slow down complex operations is, quite simply, wrong. They usually have a negligible impact on speed, and can often speed things up. Frequently the order on the checklist was chosen for efficiency -- doing things out of order works, and is equally intuitive, but slower. You spend less time thinking about what to do next. You never stop to wonder whether you remembered to do a step, and then wasting time going back to check a setting.
I would *not* advocate making such things legally mandatory -- there's simply too much inertia to laws, and they're likely to be either so vague they're useless or so detailed they interfere. However, having the people involved write and use checklists for the things they're doing becomes very important as the complexity rises.
Part of the benefit of checklists is that you can pause things. If patient 37 needs a bunch of things done, but none of them have to get done *right* *now*, and then patient 14 develops an emergency, you can put down the checklist and rush to the other patient. After the emergency, you return -- and you're far less likely to forget a step or repeat a step, since the nurse was checking them off while the doctor did them. You can't be a slave to a checklist any more than you can assume any other tool is always appropriate. Part of the job of the skilled operator is to know when to ignore the checklist. Decisions to ignore the checklist should *always* be conscious decisions, not forgetfullness.
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.
Yes, CMMI...
That way the doctors and nurses can sit in meetings all day about evaluating and achieving CMMI levels...
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.
There is a hopeless lack of process in the medical industry. They need a good solid dose of ISO9001 or CMMI.
Or simply more nurses.
bickerdyke
Or just better ones?
Confucius say, "Find worm in apple - bad. Find half a worm - worse."
Nah. Mostly we could even do with worse ones. Many of the tasks of a nurse don't require special training. (Like handing that glas of water to the woman that can't reach it, making sure that guy doesnt faint on his way to the toilet and falls to the floor out of reach of the alarm button.) On the other hand, a ringing buzzer may also be a sign of an emergency. So every buzz (service and alarm are indistinguishable) has to be answered as soon as possible.
So for five simultanious alarms, you need five people, not a single better one.
bickerdyke
After becoming a pilot, I became a firm believer in checklists and brought them into my computer work. I make checklists for software delivery processes, framework installations, toner cartridge changes, etc. Then I ask someone else in the team to carry them out while I watch over their shoulder. And then I make improvements and put them in a well-known directory. My vacations are never interrupted anymore. ;-)
Devon
The issue is that proper SCIENCE has little room for heroes. If science and engineering is performed correctly and documented, you catch mistakes before they cause problems. 90%+ of all things treated at the hospital have a regimented treatment laid out by mountains of research.. the trouble is matching the proper research to the problem, then executing the treatment exactly as the research was proofed.
Your example is exactly the kind of non-engineer thinking that needs to stop. Somebody, has generally already done the research. It's up to the doctor to apply the research... it's boring, tedious work, with a result from a book.. like what engineers do. 75%+ of engineering work is hitting the books to find parts that are already for sale to do what you want, the rest is spend defining the problem and running tests very little time is actually spend designing physical devices anymore.
The same with medial science, people need to use computerized systems to track their progress against the mountains of research already done. Science only works with control groups... if you make 2 mistakes per day, you do not have your patient's treatment under scientific levels of control... there for you are not doing science, you're doing art.. like an english major.
The gain is 1000 lives/year. Can you show that your conjecture will result in more than 1000 lives/year lost? That's a rather tall order.
I would like to echo the point about the burden of documentation and responsibility. In Gawande's book Better he ponders why medicine wards aren't run like operating rooms to control infection. The reason is cost! It would be great to have a procedural check list for each patient, and protocol list to select the correct procedural list, and etc, with a dedicated individual assigned to each patient to make sure everything is being followed appropriately.
The point physicians/nurses don't need engineers to create checklists for them, so that they can take care of one patient. They need a way of doing it for 50 patients at once, that need 200 some tasks per day...this requires re-structuring everything that is in the job description and expectation from the patient.
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
The point of checklists is not to stifle creativity, it is to bolster memory and stifle mistakes.
If you look at the checklist, think about it, and decide to not do one of the steps or do that step differently, that's innovation. It may have a good result or a bad result, and your reward or punishment will depend on the result. But it was intentional. If you make an intentional choice and the result is good, you can change the checklist.
If you don't have a checklist, and you forget an important step or you do it wrong, that's a stupid mistake that should never happen. If you make an accident like that, most of the time you don't notice, you just wonder why this patient died. And even if your accident works out for the better, you cannot change the way things are done because nobody knows what you did differently.
I hate it when I make a joke and I get modded "+5 insightful". Mod the stupid comments "funny", not "insightful", pleas