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.

Comments

Look at Airplanes

[corsec67]

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."

Re:Look at Airplanes

[evilad]

Aviation checklist users suffer from a condition that I'll call "known-data blindness" for lack of a better term.

I've run the C-172M checklist several hundred times, and let me tell you, it's *very* easy to lose track of your place in the list, and forget whether your memory of having completed a given item is from this evening's flight, or from the one you did this morning.

This is almost never deadly in a beast as simple as a fixed-prop, fixed-gear Cessna 172. Come to think of it, I've *never* caught a condition with my checklist that would have killed me, had I missed that item.

My personal experience leaves me wondering if it's possible that checklists could cause obvious things to be *missed*.

The problem could be easily fixed with dynamically generated checklists that cannot be answered without having read and comprehended the question... but that would slow things down so much that I bet it would cost more lives than it would save.

Re:Look at Airplanes

[evilad]

Thanks for that. Apparently I skimmed the article a little too quickly. Imagining myself in both positions in the cockpit, I'm inclined to agree. Steps would rarely get missed or performed incorrectly. A far superior system to what I've been doing.

I wonder if delegating checklist-reading to a non-pilot passenger would fall under "good crew-resource management" or "gross negligence".

Re:Look at Airplanes

[Chapter80]

Your comment reminds me of a programming anecdote that I have told here before. We are responsible for a software package that coincidentally has patient data in it (but this applies to all sorts of applications).

The medical staff was supposed to log all interactions, which range from medicines administered to having a conversation with the patient or parent/guardian. Everything was to be logged, so that nothing was forgotten. And nothing could ever be deleted, by design.

Well, people made mistakes (the nerve of them!), and sometimes a record would be entered on the wrong patient, and you'd really WANT to delete that misleading information. This spawned numerous debates as to whether the we should really remove the erroneous information, or mark it as bad information. For instance, if Note 5 was that a certain drug was administered, and a Doctor relied on Note 5's misinformation to do whatever was done in Note 6, by deleting Note 5, you remove the defense and rationale of the Doctor.

Likewise, if you allow temporary removal of a note, then you allow someone to "undelete", you could end up in a similarly indefensible position. Note 5 correctly says that full dosage was administered at 10PM. Note 5 gets inadvertently deleted (recycle bin). At 10:05, a nurse sees that no dosage has been administered, so administers another full dosage, and logs it as Note 6. Someone undeletes Note 5, and makes the nurse look incompetent. Patient dies. Nurse got framed. All bad.

After all these discussions, at the direction of the administration, we built a permanent delete function, so that these erroneous notes could be permanently removed. No "recycle bin". Heavy logging of what transpired and when. And an alert window warning the user that they are about to perform an irreversible action of delete.

... and the "known data blindness" (or something like it) caused people to click through the warnings. How many Windows Alert boxes do users get per day, where they just press OK. Well, we kept getting requests to "undelete something that I just deleted", even though we warned them with a Windows Alert box.

So we made the warning bigger and longer and wordier. And the rate of calls to undelete something went UP.

Finally we changed the alert box to prompt the user to do something different. In order to complete the Delete function, the user had to key in the word "irreversible" into the alert prompt.

Requests to undelete went down to near-zero.

Re:Look at Airplanes

[icebrain]

Too many people treat checklists as "do lists", meaning they go down the list step-by-step, doing each thing as they go down. I've seen this a lot among small-airplane pilots.

In large aircraft, the crews use "flows" performed from memory (usually tracing a particular path around the panel, hence the name), followed up by a checklist to catch the critical items. This way, you're not cluttering up the list with mundane little things--the more things on the list, the easier it is to miss one of them because you lost your place or whatever.

A better article on the subject: http://www.avweb.com/news/leadingedge/leading_edge_checklists_and_flows_194990-1.html

Yes, and it's called LifeWings

[spineboy]

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.

Re:Yes, and it's called LifeWings

[MichaelSmith]

A couple of days after our son was born I left my wife alone in her hospital room. She was sitting up to feed the baby but started slipping off the seat. She pressed the call button for a nurse but nobody came. Eventually she use the phone to call reception and they sent a security guard up to help her. The call light had been on outside her room but none of the nurses had decided to respond.

There is a hopeless lack of process in the medical industry. They need a good solid dose of ISO9001 or CMMI.

Re:Yes, and it's called LifeWings

[JohnnyBGod]

At least where I'm from, there are people to do those kinds of jobs. I believe the translation would be "nursing support staff", or something similar.

Re:Yes, and it's called LifeWings

[arth1]

Kind of all people in medical care is awesome. They are nice people, well educated, work their ass of and don't get paid what they deserve but love people so they carry on. To blame them is so wrong in so many levels.

The health care industry has its share of bad apples, just like any other barrel.
There will be disinterested nurses and doctors, as well as plain stupid ones. And their will be highly interested and skilled ones too.

This problem can be attacked in many ways. The way that Mr. Provonost wants is the typical corporate American way, with more control and procedures. Give people less rope, and it's less likely that they'll hang themselves with it. Yes, it leads to measurable effects, at least in the short term, but the long term effect could be to scare away the highly interested and skilled professionals, who will wither in such an environment. After a generation, you'll end up with health care professionals who are as good as your typical store clerk, i.e. someone with absolutely no interest in the customer.

Another way to attack the problem would be to try to adjust the ratio between good and bad staff. Increase both the carrot and the stick. Allow bonuses for going above and beyond duty, and allow firing of those who show no interest in their work, even if they perform it to the letter. And hire enough staff that a few slackers (or nurses home with the same cold) won't affect the overall efficiency too much. Then give the staff more rope, not less. Let the highly skilled people make more decisions, and defend them when they do so, by making it illegal to sue hospitals for trying to help you -- only for lack of trying. As it is today, if a doctor has a choice between a procedure that slightly improves 70% of the patients and does nothing for the rest, or one that cures 95% and maims 5%, he will almost always have to go for the former, cause the 5% unlucky ones will sue.

Re:Yes, and it's called LifeWings

[mabhatter654]

no, even the best people WILL make mistakes even if they're just small ones. That's the whole point of things like ISO or QS that somebody ELSE is looking for those mistakes. Imagine if GM made one mistake per worker, and they allowed 2 mistakes per Auto off the line... oh, wait that happened and they nearly died. 1 mistake per worker each day is intolerably high in a world class environment.. and Nurses and Doctors are all Bachelors degree or higher, that's the top 15% of all workers already. You don't get better without scientific help.

Re:Yes, and it's called LifeWings

[Gilmoure]

Yup, I was a medic in the Air Force. In military medicine (at least Air Force hospitals), the medics (EMT/LPN licensed) out number RN nurses about 5 to 1. Also, due to reduced personal liability (military won't hang you out to dry to lawyers, except in cases of obvious dereliction of duty), they pushed many tasks that civilian RN's are require for, onto the techs. And things were rather well run, when I was in ('89-'93). Even in the VA hospitals I worked in (part of OJT), things seemed to be doing pretty well. Now, after seeing the horror stories of the last few years, of military care, 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.

Re:Yes, and it's called LifeWings

[Robyrt]

Or perhaps have two separate nurse buzzers, Service and Alarm? Hire support staff for Service calls while the RNs go around handling Alarms.

Re:Yes, and it's called LifeWings

[fprintf]

On the day that my son was born I almost lost my wife. She had a C-section and was not doing well from the blood pressure medication. I was visiting her in the recovery area and the blood pressure alarm started going off, notifying me and the nurses at the call station. I watched as her blood pressure went down very very low but no one came. I went out to the call station where the nurses were standing around chatting and said "I don't know if I should be worried or not, but the blood pressure monitor alarm is going off in the room and out here".

I got pushed out of the way, another alarm sounded, a Doctor arrived, and they started pulling these huge blood clots out of her (I could be more graphic, it was seriously gross and very involved). Shortly afterward the doctor said to me "son, you are a hero. Your wife was a few minutes away from dying from blood loss due to hemorraging". I was || this close to being a widower... not because they needed more nurses, but the ones they had needed to pay more attention.

Personal anecdote - it works!

[bertok]

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.

At $107 per life...

[Jane Q. Public]

it seems like a good investment.

Re:At $107 per life...

[Chapter80]

While I'm a firm believer in checklists, I have my doubts about the study. It sounds to me like this might have been conducted by a guy who has a bias toward having checklists (which I do too).

It'd be difficult to measure how many lives were saved by the checklist (as opposed to other factors). I bet he looked at the deaths, and then looked for mistakes in procedures (that could have been avoided with a checklist).

But there are some serious issues with this methodology. Were these patients going to die of something else? Would the checklist have prevented the mistake? And how many patients inadvertently lived due to mistakes that would have died, had checklist procedures been followed?

This message was posted in Slashdot tradition - without reading the article.

Re:At $107 per life...

[tg123]

............. It'd be difficult to measure how many lives were saved by the checklist (as opposed to other factors). I bet he looked at the deaths, and then looked for mistakes in procedures (that could have been avoided with a checklist). ................

I'm not sure if your getting the point of the article.

The article explains that in the "ICU" the technology exists to save people who would normally have no chance, If and only if, the proper procedures are carried out.

One person or a piece equipment not being available at the right time could be the difference of a patient living or dying.

With a checklist care can given in a consistent and methodical manner.

Towards the end of the article it talks about the little Austrian girl and that previous to her there had been many unsuccessful attempts at resuscitation. Each time they would get a brief glimmer of hope only for a person to be missing or a procedure not followed. When they started using a checklist people started surviving.

Re:Just another fad

[dorpus]

Let's compare apples to apples. What if you were in a rocket engine testing facility where dozens of rocket engines are simultaneously in danger of failing, and all the rocket engines had to keep running at all costs? Would you want to go through the formality of checklists? If ICU patient #37 died while doctors were going through the checklist for patient #14, won't the media headlines scream that "ICU patients die while doctors are held up by hospital bureacracy"?

There is an interesting recent article that shows how fire extinguishers are harmful to public health; 4% of fire deaths each year are caused by amateur operators who attempt to extinguish flames with their "mandatory" fire extinguishers. As the paper states, "As described above, in terms of life safety (as opposed to preventing material losses), attempting to extinguish a fire is not effective. For a fire extinguisher to work, a fire must be small, accessible, and not producing large quantities of smoke. In the face of such a fire, the safest course of action is to evacuate the area.... Fire extinguishers require extensive training to be used effectively. Using a fire extinguisher exposes the operator to physical danger and in terms of life safety--evacuation, as opposed to attempting to extinguish the fire probably represents the best option."

Mass hysteria has mandated "safety" laws before, which have turned out to do more harm than good in the long run.

Prog Cardiovasc Dis. 2008 Nov-Dec;51(3):204-12.

Checklist has problems though

[Secret Rabbit]

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.

Re:Get rid of the dinosaurs

[jimicus]

It's amazing how resistant 'modern' medicine is to basic proven work flow improvements such as checklists, treatment guidelines.

It's not just modern medicine - this has been a problem since more-or-less forever. Go and look up a little medical history about the early use of antiseptics, anaesthetics and even such basic practices as good hygiene.

There was a documentary shown a few weeks ago in the UK about a 19th century doctor who noticed that births attended by doctors had a much higher fatality rate than those attended by midwives - he eventually figured out that hygiene had something to do with it and started making sure he and those working under him washed before visiting the maternity wards. His fatality rate plummeted but still the majority of doctors refused to change how they worked and he wound up literally driven insane because he had worked out how one could easily save thousands of lives but nobody was prepared to even give his idea a go.

Unfortunately I forget his name now so I can't easily find more information to point you at.

Why it's not done

[Thelasko]

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.

Gathering of success rate data shut it down

[Fencepost]

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.