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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.
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.
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.