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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?
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
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.
Sure thing, Malthus.
I agree that the earth cannot possibly support more than a few million people, a hundred million absolute tops.
I'm gonna need a spec.
"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"
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
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.
it seems like a good investment.
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:
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.
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.
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.
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.
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 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".
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
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