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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.
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.
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.
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.
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.
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.
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.
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.