
Hospital checklists are meant to save lives, so why do they often fail? - areoform
https://www.nature.com/news/hospital-checklists-are-meant-to-save-lives-so-why-do-they-often-fail-1.18057
======
OliverJones
I wonder. Does the Hawthorne Effect
([https://en.wikipedia.org/wiki/Hawthorne_effect](https://en.wikipedia.org/wiki/Hawthorne_effect))
contribute to the success of these checklist regimes?

When surgical or emergency-department teams believe they're participating in
an experiment to learn whether certain practices improve outcomes, do the
outcomes improve?

Airplane pilots use checklists. It's illegal to start the engines unless the
approved checklist book is within reach of the pilot in command. In training
it's drilled into us that the response to panic is: get out the checklist and
follow it. It works. duh. It's all too easy under pressure to forget to lower
the wheels or turn on the carburetor heat, or whatever. The drilling in
training is what makes the difference.

(Aviation gasoline cools as it vaporizes in carburetors. Under certain
conditions that can make the carburetor fill up with ice. If that happens the
airplane will land soon. Not good. So carburetors have heaters. )

Checklists have far less success in medicine. Heck, almost two centuries ago
Dr. Ignatz Semmelweis
([https://en.wikipedia.org/wiki/Ignaz_Semmelweis](https://en.wikipedia.org/wiki/Ignaz_Semmelweis))
found that patients lived a lot longer when doctors and nurses washed their
hands.

But, even in the 21st century, it's a struggle to get compliance with hand-
washing rules in hospitals. Maybe something about medical training makes
people resistant to fixed procedures. Maybe it's the age-old practice of
eminence-based medicine rather than evidence-based medicine. It's a serious
problem.

~~~
mschuster91
> But, even in the 21st century, it's a struggle to get compliance with hand-
> washing rules in hospitals.

Ever talked with a nurse or a doctor? The reason is simple: way, way not
enough staff at hand combined with maximum allowed/planned time for a certain
procedure (e.g. 10 minutes for a full assisted shower) which only works in
perfect conditions but falls apart under the slightest change (e.g. patient
wet themselves), and combined with ruthless MBA-style C-level execs actually
firing people for not keeping up with the numbers.

Medicine, especially highly critical / urgent care, needs to be socialized and
shielded off from all negative effects of modern-day capitalism if this is to
change.

~~~
sarcasmOrTears
You want to solve a problem caused by shortages with policies that
historically always causes shortages? (Socialism)

Medicine is heavily regulated everywhere and people always complain about the
same problems in the US and Europe, and these problems are the same kind of
problems caused by regulation and guild-like organizations all around the
world, in all industries at all points in time.

Even if you were to let someone else pay the bill, it's idiotic to have things
organized as they're now.

~~~
JudgeWapner
There wasn't a nursing shortage back when the county ran the hospital in my
area. But you know the laws of supply and demand: corporations have to
manufacture scarcity to drive up KPIs

------
heymijo
An ophthalmologist I know is an attending physician, which means she teachers
new resident physicians.

She described a few surgeries to me and her role in the room as the resident
performs the surgery. Her brain is the checklist for the surgical procedure.
The culture seemed to be, you should be good enough to memorize these complex
procedures.

Meanwhile I'm thinking, why not just have someone else in the room reading and
confirming the next step to the surgeon?

I suspect the culture of medicine, and especially the culture of surgeons does
not jive well with checklist culture.

~~~
joshgel
This [1] is a great article that I think gets at this topic a bit. Basically,
germ theory and anesthesia (ether) were both discovered around the same time.
Yet anesthesia spread around the world in a matter of years, while germ theory
is still a struggle for doctors and hospitals. I presume the reasons
checklists are underutilized are similar, lack of immediate consequence, low
probably of consequence, and added difficulty instead of simplifying things.
We must do better.

[1] [https://www.newyorker.com/magazine/2013/07/29/slow-
ideas](https://www.newyorker.com/magazine/2013/07/29/slow-ideas)

~~~
Scoundreller
Ether was a new tool that lets you do something you couldn’t do before.

Checklists were a new tool that required you to submit that you’re stupid and
should depend on inanimate paper to do what you already know.

~~~
arrosenberg
Maybe part of medical training should include the difference between stupidity
and fallibility then. If you made it to med school, you probably aren't
stupid, but you are human.

~~~
viraptor
I'd go with: part of any training for complex tasks. And even to kids in
general. There are so many people I met who can't imagine that others make
mistakes without any real reasons, which leads to unnecessary conflicts or
workplace issues. It just happens - plan for people failing, not for punishing
random failures.

------
conorh
They fail because of severe checklist fatigue according to my wife (a
surgeon). Checklists are great - so let's do them for everything, ALL the
time. People start to tune them out because they do the same checklist
hundreds and hundreds of times and they often have many irrelevant things on
them. The people using the checklists have little ability to change them or to
improve them and so they start to suffer from checklist fatigue. As they say
in the article:

> “There's no point in having an item that says, 'Have the antibiotics been
> given?' if there are no antibiotics in the hospital,” says Dixon-Woods.

The checklists that my wife uses are apparently filled with these types of
irrelevant checks.

Not to say that they aren't useful, they are, but as this article points out
the implementation of checklists often leaves a lot to be desired.

~~~
y0ghur7_xxx
> They fail because of severe checklist fatigue

> checklists often leaves a lot to be desired.

You say yourself that checklists are great, and it is proven that they save
lives. So if there is fatigue in using them over and over, and they are not
perfect, well... get over it? Sure i can understand that it's boring to go
through the same checklist 5 times a day, but come on, there are lives at
stake here. If one of your wife patients gets an infection and dies because
she forgot some important, simple, step because of "checklist fatigue" how
would she feel?

~~~
crazygringo
I don't think that's what checklist fatigue means -- it's not about boredom or
tedium.

It means that the more you keep having to skip over irrelevant items and the
more you still depend on remembering other things that aren't on the
checklist, the less likely any human being is to reliably follow the checklist
-- because they accidentally skip over an item thinking it was the irrelevant
one, or jump back to the wrong item (skipping others) because they got "off"
the checklist to do steps that weren't on it.

The point of a checklist is that it's supposed to be a single idiot-proof
source of truth in a specified area, reducing mental complexity and therefore
reducing errors.

Once it stops being that because it isn't perfect, it can easily _increase_
mental complexity which requires _more_ brain use and increases errors. _That
's_ the fatigue.

So it's not a question of just "getting over it".

~~~
UK-AL
Keeping a checklist up to date is incredibly important.

If you have skip items on a list, then human error pops up again

------
monocasa
I like what they do in the Japanese train system. You have to point at
whatever you're doing and day aloud what it is before you check it off. That
heavily reduces the amount of mindless checking via scanning the sheet that
leads to items being checked off without being fully validated.

[https://en.wikipedia.org/wiki/Pointing_and_calling](https://en.wikipedia.org/wiki/Pointing_and_calling)

~~~
ChicagoBoy11
I fly private planes as a hobby and during my training that practice was kinda
grilled in to me. After flying for a bit, you end up realizing how easy it is
to "see" something incorrectly, or to skip an item, etc. Even when there's no
one else in the plane with me, I say things out let, touch nobs to confirm
their position even though I checked it earlier and didn't touch the nob at
all at any portion in the flight. (Good) Pilot training will make you aware of
just how much trouble your mind can get you into.

~~~
thrownblown
Both of you have fat fingers.

~~~
behringer
I hope the landing gear isn't next to the ejection trigger.

~~~
thrownblown
In my defense downvoters, they both had typos, "day aloud" and "say things out
let" and we're talking about pointing and touching dials here.

~~~
behringer
I got your back :)

------
sopooneo
I've never worked in a hospital, but I have plenty of experience with massive
bureaucracies. And that gives me guesses, perhaps fanciful, about things that
could go awry with surgical checklists. Anyone with relevant experience,
please weigh in if these seem feasible.

1\. Every prominent error that occurs prompts administration to decree a new
checklist item be added to provent it in the future. But these added items
will not be root-cause fixes so will proliferate to the point that there are
now several dozen of _negative checks_ to prevent these one-in-a-million
mistakes. And so the lists will grow and grow, but no one will ever dare to
take an item off. Because then if that mistake ever does reoccur, the admin
that authorized its removal is up for a hearing in front of the firing squad.

2\. Some administrator somewhere, noticing redundancy within a given checklist
will reinvent _control structures_. You'll have lists with loops and
conditionals. And since the people creating these lists don't know what is
"considered harmful" they will almost certainly add GOTO's. In fact, I'd be
very surprised if GOTO's don't already exist in surgical checklists somewhere.

But then this addition of control structures could increase to the point that
a surgeon could, potentially, be put into an infinite loop! So committees will
be formed to ensure every path through a checklist actually can be completed.
And someone, somewhere in a hospital conference room, when asked to PROVE the
lists all terminate, will take a breath, sit back, and rediscover the halting
problem.

~~~
therealx
Some patient record programs already allow control structures in the digital
forms. Basic stuff like if(X) then show options Y or page Y - you get the
point. I think I saw a goto type item last I checked, which was a little bit
ago.

As offices go digital, some are doing it right and recreating the forms in the
signing application. Other, lazier firms, have you fill out a scan (gag me
with a spoon.)

The idea of a loop is a funny one, I wonder if anything checks for it?

------
adolph
Key point is the last paragraph:

 _Fortunately, Fixsen says, the lessons of implementation science are
“completely generalizable”, and all programmes could benefit by noting the
importance of engaged leadership, local adaptation and user buy-in. “It doesn
't matter how good the innovation is, it doesn't matter how much has been
invested,” says Fixsen. “If we don't have the implementation savvy, we're
going to get the crummy outcomes that we have seen decade after decade.”_

------
rscho
Official role for checklists in healthcare: save lives!

True role of checklists in healthcare: save management in case of legal
action.

Consequence: the checklist becomes longer and longer, and is done more and
more frequently. To the point of being quite impractical.

Goal: in case of legal action, take refuge in checklists. At least one of the
items is bound to be missing so you can divert responsibility to someone else.

Source: I do checklists. That's my job.

~~~
tonyarkles
I replied elsewhere in the thread with a bit more detail, but my UAV
checklists contain 100% material learned from experience _only_. They've grown
a little (especially the packing list) as I've gotten out to the field and
realized I didn't have a tool that would be useful to have, but they've also
shrunk as I've eliminated equipment I no longer need (e.g. a programming cable
for an ESC that I no longer use).

It's pretty disappointing to hear that that's how checklists work in your org.
I feel like it's doubly negative: not only does it pretty much guarantee that
they won't be followed because they're not particularly useful in that form;
it also helps to ensure that the folks that have to use them will push back
against checklists in general at their next job!

[I suppose that's what happened with me and JIRA too... it might be a decent
product, but every org I've used it in has done a very bad job with it]

~~~
baud147258
I think our boss has made a good job with our bug workflow, but she had the
authority (and Jira access) to do what she (and the QA lead) wanted.

------
hestipod
They fail because of egos and arrogance. This is the root cause of a lot of
life's problems. People think they are above it and too smart etc. They hate
being "told what to do". An example, I have a family member who will complain
about texting and driving from some position of superiority but who does it
constantly himself. When challenged with that behavior he refuses to
acknowledge it. He believes he is above it, better than those who cause
accidents, and only those "lesser" people need to follow rules. It's an
incredibly common behavior and doctors are no different...and in some cultures
more likely to assert their status.

~~~
stronglikedan
> He believes he is above it

Honestly, he probably is. We need to have laws because _most_ people do it
carelessly. Not necessarily because _all_ people do it carelessly. Naturally,
those who know they do it safely aren't going to just lump themselves in with
the majority that don't.

~~~
vangelis
Most people who text and drive are doing it safely until they aren't. It only
takes a second to fuck up.

------
srikz
I was just thinking about the comparison between the medical industry and
airline industry. In medicine you can (or have to) pay a premium to get the
best doctors and expertise [1]. In the airline industry, the safety aspect is
standardised across the board.

It doesn’t matter if you are flying economy or 1st class you get the best in
class safety, which is collectively shared across the industry. We pay a
premium for the service and not to have better chances of surviving.

In an alternate universe, we could have had cheaper airline tickets which had
not so great safety record and the good ones only in reach of the super
wealthy.

[1]: I’m aware it may not be the case in some countries with completely free
healthcare, but this applies to the majority of the world. Even in those
countries with free healthcare for all, it is not uncommon to see huge wait
times for some important procedures and being able to skip it by going through
a private hospital.

~~~
GhostVII
I think the big difference is that with airlines, it is realistic to have a
zero-tolerance approach to deaths, since the default expectation is that a
plane will not crash. With hospitals, deaths are innevitable, so you can't
just have a uniform set of regulations to ensure no one dies.

Also, I think you can definitely pay more to go on a safer plane - I would
imagine more expensive airlines have newer planes and better maintenance - but
the risk of death is so small it isn't worth the extra cost.

~~~
sergioj97
Things like this make me wonder: is it really worth for the airlines (I'm also
talking about plane manufacturers here) to be this secure? I would assume it's
not different from the automotive industry, where the security of your product
depends primarily on financial reasons.

I feel like many people would be willing to trade some security for better
ticket prices.

Of course there are differences with the car industry, one of them being the
economic value of the vehicle and thus the loss in case of accident. I don't
know if it would actually be profitable for them.

~~~
tzs
One big difference between the airlines and the automotive industry (or
doctors) is that with airlines a crash doesn't just kill the paying
passengers. It also usually kills the pilots and other crew.

This sets a floor on airline safety--it has to be safe enough that the
airlines can readily find pilots. Some passengers, especially those who rarely
travel, might accept more risk for a better price but I suspect that pilots,
who might be making hundreds of flights a year, would not be so willing.

~~~
lonelappde
Indeed the pilot and flight attendants unions are leaders in driving safety
procedures in aviation.

------
wisty
A lot of people seem to be hung up on the fact that there must be something
special about doctors. They're too skilled, they operate in a unique
environment, or that they're awful egotists with god complexes.

Pick almost any profession other than pilot, and checklists are something that
most people will ignore, often for the same excuses doctors have.

It seems like it should be comparable, as both medical errors and aircraft
crashes are taken seriously, but there's a huge difference in magnitude.

------
WalterBright
Checklists have been incredibly effective in improving aviation safety. But
just having checklists doesn't help much - there has to be a culture of
following them and a ritual to following them.

~~~
mjevans
When followed correctly it is my believe that checklists can raise the floor
of the worst case outcomes. Said another way, actually following the checklist
eliminates the low-hanging fruit of preventable mistakes.

~~~
noir_lord
Not a pilot but I follow mine rigorously when doing rote tasks I haven’t
automated yet and they save me from a lot of head slapping moments.

It’s a habit I had to work hard at, item one on my list is usually don’t skip
any steps.

------
dctoedt
Atul Gawande's book, The Checklist Manifesto, said that WHO's surveys found
significant resistance by surgeons to using checklists — but if _they_ were
going to be operated on, something like 93% of the surgeons said, in essence,
_you 're damned right I want the surgeon to use a checklist._

------
charles_f
Article seems to identify main reasons as either poor implementation, or poor
change management. Funny how much this reminds me of capital-A-gile, and
Jeffries "we've tried baseball"[0]

\- we've implemented some simple changes that make things better!

\- everyone, let's all do this thing!

\- there! We've tried! It doesn't work

\- but you've bastardized the original idea beyond recognition

\- doesn't work!

[0]
[https://ronjeffries.com/xprog/articles/jatbaseball/](https://ronjeffries.com/xprog/articles/jatbaseball/)

 _edit: formatting_

------
mieseratte
Does anyone here use point-and-call or something similar for more mundane
activities than trains and planes? I started doing this while driving a few
years ago. I've gotten a good bit of shit over the years for it from skeptical
passengers. Hard to point at a clear-cut win when it is about prevention.

~~~
marcosdumay
I have a "punch every item" list for going out of my work building through the
stairs, with the minimal necessary to be sure I can get back through the
elevators and I have my belongings locked.

I do point and call a recipe ingredients when I try to cook. I would love to
make a point and call routine for packing travel bags, but their 3D nature
makes it hard.

~~~
mieseratte
> I have a "punch every item" list for going out of my work building through
> the stairs

I have a little "dance," slap left-pocket (key / clip), slap right-pocket
(phone, wallet), slap left-pocket again (double check keys), slap right-knee-
pocket (knife). I should throw in a foot slap to make folks think I'm doing a
Schuhplattler on my way out the door.

> I do point and call a recipe ingredients when I try to cook

You must have a nice spice shelf. I have 30+ spices in a narrow cabinet.
Finding the right 4 is a chore unto itself.

~~~
tolstoshev
Spectacles, testicles, wallet, watch! :)

------
skybrian
If something as seemingly straightforward as using checklists is difficult to
implement in hospitals, maybe we shouldn't feel too bad about the slow,
partial, and controversial adoption of programming methodologies?

~~~
marcosdumay
Oh, our profession moves very quickly and very universally. It's unparalleled
on that.

The controversy is usually about wether the movement direction is any good.

------
dctoedt
In aviation and nuclear-reactor operation, the ethos is that 1) _of course_
people are going to make mistakes, because we're human; 2) the point of
_systems_ such as checklists and second-checking is to try to make sure the
mistakes get caught before they have any effect; so 3) if you harbor
resentment toward checklists, try to give yourself an attitude adjustment —
learn to embrace and even enjoy them.

------
wysifnwyg
Doing UX Design right now and the popular phrase is: "If only people would
read instructions everything would be alright."

------
justinmeiners
As the article states, the issue is they are often poorly implemented or
designed. If that's the case, what is surprising?

------
iamleppert
Sounds like a great opportunity for a digital checklist with a computer
vision, audio analysis component and deep learning backend that could
quantify, and eventually automate the adherence to such checklists.

I wonder how many people would actually follow the checklist if they knew
their compliance was being continually monitored and audited?

~~~
scott_s
I think that misses one of the lessons of the study: people need to be
invested in the checklist for it to help. In other words, they need to _want_
to go through the process. The checklist itself is not magical. When it's
effective, it's because it formalizes everyone's desire to adhere to agreed-
upon protocols that everyone agrees are beneficial.

~~~
sergioj97
Even though it seems clear that the checklist itself has to be well designed,
I don't think it's a bad idea to ensure they are followed. Strategies like the
one the OP proposed are independent from checklist quality.

------
cortesoft
I also wonder how much of an effect the prior conditions have... if a hospital
is already doing a good job of following procedures without a checklist, it
might not make as much a difference as for a place that wasn't doing so well
before.

------
rb808
Checklists are way overrated. To all the fanboys out there, how many of you
regularly have checklists for things you do several times a day?

I know in the last ten years I've seen new processes with forms to fill out
for mundane tasks and its PITA.

------
cardiffspaceman
In the documentaries about Apollo 11 that are rather easy to find these days,
one of the things you hear over and over again is the "go"'s from various
participants right before a launch or other milestone.

~~~
gpm
If you watch a modern rocket launch (the vast majority of which are
livestreamed and uploaded to youtube) you hear the same.

------
casion
I read the article, but I don't see if/where there is responsibility given for
the checklist(s).

Most QA systems have a source of responsibility and multiple levels of review.

I wonder what would happen if there was a QA team (with sufficient education)
at a hospital that had complete control over checklists and associated
procedures. Would that improve the outcome when utilizing checklists?

\--- Anecdote ---

I've been in the hospital many times, and I've been present for pre-surgical
checklists a few times. It was ALWAYS a nurse handling it, and it was never a
nurse that I was familiar with during my care. All but once the interactions
started with trying to figure out who I was... without asking me.

I can recall a number of times where there was a question, such as "Which body
part is being operated on?", except I was told the answer. The "question"
turned into "Looks like your right kidney is being removed", with a slight
pause for me to object.

It always made me feel like the staff thought the purpose of the checklist was
to complete the checklist, rather than to QA the system they're part of.

\--- Anecdote Extended ---

I suffered an unpleasant complication from this during a procedure.

I do not respond to anesthetics the same way as most people. It takes a MUCH
larger dose to knock me out, and to keep me out. (years of desensitizing
medications \+ big (very tall) person + MC1R gene).

I know this. I can communicate my past procedures and the doses administered.
USUALLY they are supposed to ask if you've had any prior procedures and
potentially follow up with questions about allergies, anesthetics and other
questions related to sedation.

I was not asked. I didn't think to speak up because I was already being
inundated with stimulus.

The result? The first "count down from 10" resulted in me counting to 0 and
asking "What next?".

I vividly remember the abject horror on the face of the nurse. She fumbled
around, whispered to the anesthesiologist, whispered to other nurses. People
shuffled around and nobody said a word to me.

I was scared. It felt like forever before I was asked to count down from 10
again. It worked that time...

Until I woke up in the middle of the procedure!

When I woke up in post-op, I asked the nurse about it and she told me that I
wouldn't remember any of it. She told my wife that I wouldn't remember the
couple hours after post-op.

I remember every single nurse's and doctor's name involved and the discussions
my wife had with the doctor in post-op (which she confirms my recollection).

It could have all be avoided if someone just said, "Hey, have you had a
procedure where you've been under general anesthesia before?"

I bet that checkbox was ticked though.

------
neom
I've tried to read The Checklist Manifesto twice now, and I couldn't because
I'm too squeamish.

------
mhb
If I saw both _Mark the surgical site_ and _Introduce yourself by name_ on the
list, I would also be suspicious about which items were saving lives and which
were wasting my time.

Separately, maybe it would work better to give the checklist to the patient
and have her check off the items.

In light of some comments, it appears I wasn't clear. My point was that the
problem is having BOTH those items on the list. Marking the surgical site is
definitely worthwhile. Having it on the same checklist as introducing yourself
dilutes the importance of it and the other important items on the list.

~~~
jcwayne
"Hey there Mr. Smith, I'm Dr. Brown. I'm going to be doing blah, blah, medical
stuff, right here on your left abdomen." ... "Well that's the right spot doc,
but I'm Mr. Jones."

~~~
walshemj
Interesting in the UK your continuously responding with your name and hospital
number maybe there is more turnover in the US system.

Though I am a long term patient with a chronic condition so that might make a
difference.

