
Post-surgical deaths in Scotland drop by a third, attributed to a checklist - fanf2
https://www.bbc.co.uk/news/uk-scotland-47953541
======
LeonM
My former roommate is a pilot. When I first met him, I noticed that he uses
checklists for just about everything, even the most basic everyday tasks.

After some time, I decided to apply that same mentality to my own life. Both
in private and work situations.

I get it now. Checklists reduce cognitive load tremendously well, even for
basic tasks. As an example: I have a checklist for when I need to travel, it
contains stuff like what to pack, asking someone to feed my cat, check windows
are closed, dishwasher empty, heating turned down, etc. Before the checklist,
I would always be worried I forgot something, now I can relax.

Also, checklists are a great way to improve processes. Basically a way to
debug your life. For instance: I once forgot to empty the trash bin before a
long trip, I added that to my checklist and haven't had a smelly surprise ever
since ;)

~~~
ip26
Good checklist design is not trivial, however. I use checklists
professionally, and the list rapidly accumulates cruft for problems that have
been solved by design. E.g., suppose one time someone forgot to sign your
software release. "Verify release has been signed" is added to the checklist.
However a bright soul also integrates signing into the release build. Thus the
problem is essentially solved once and for all, but the item will remain on
the checklist in perpetuity, which adds overhead & decreases confidence in the
checklist process.

I think they make sense for infrequently exercised routines of moderate
complexity that are 100% execution. A complex but limited scope machine like a
plane is really an ideal example. I guess preparing for a vacation could be
another, although I get caught up because packing is totally different every
time. I suppose I checklist myself when I rappel or go skiing ("Skins, skis,
boots, ... _working up the body_ ")

~~~
ghaff
I confess to not usually using a checklist when I travel because most times
are a bit different. What I do though--I travel a lot--is I have a couple
containers of "travel stuff" down in my kitchen including some pre-made kits
that I just throw in my bag. I pick out what I need, add clothes as needed,
and that works pretty well.

~~~
mason55
> _I confess to not usually using a checklist when I travel because most times
> are a bit different._

Don't you find that most trips have a ton of stuff in common though? Pajamas,
contact case/solution, loofah, spare phone battery, ear plugs, phone charger &
battery charger, reusable water bottle, etc. always go with me on every trip.

IMO the stuff that always goes is the stuff that I tend to forget, exactly
because there's nothing unique about this trip that would make me remember it.
If I'm going to the beach I know I need my swimsuit and beach shirts because I
can walk through my activities and think about what I need for each one. But
I'm likely to forget pajamas because I'm not thinking about "go to bed every
night" as an activity to plan for.

~~~
ghaff
A lot of the things you describe (or my versions thereof) are in one of the
kits I always bring and the others are elsewhere in the container I rifle
through when packing. Sure, I could have a checklist (and probably should) but
forgetting the basic stuff isn't something I have a regular problem with. I do
travel every few weeks so I have the routine pretty well down.

------
intertextuality
I work on software related to medical drilling. Nurses run through simulations
(mostly a situation where something has gone wrong) and get graded.

It baffled me to learn that this is NOT the norm at hospitals. Due to the
stress of a situation-gone-awry and inexperience, some horrific things can
happen.[0][1] In some situations you may only have a few minutes to enact
corrective procedures. In any case without checklists (and without experience
from running routine simulations) it's _very_ easy to make mistakes or forget
what to do.

I thought the checklists themselves were standard but it appears not...? The
more I learn about hospitals' operating practice the more wary I become. I
have no idea why hospitals aren't like the aviation industry and have
checklists and expiring certifications. (Or maybe I heard wrong and I'm just
completely wrong here.)

[0]: [https://www.telegraph.co.uk/news/2018/05/10/premature-
baby-d...](https://www.telegraph.co.uk/news/2018/05/10/premature-baby-
decapitated-mothers-womb-gynaecologist-pulled/)

[1]: [https://www.nbcbayarea.com/news/local/Dental-Anesthesia-
Unde...](https://www.nbcbayarea.com/news/local/Dental-Anesthesia-Under-
Scrutiny-After-Child-Dies-381594491.html)

> Mead said the principal risk is a patient’s airway. He explained that a
> child’s breathing tube can collapse without warning under sedation.

> “It happens instantaneously,” he said. “You have maybe half a minute to make
> critical decisions about how you're going to manage that child's airway. You
> can't do that if you don't have somebody competent there helping you.”

~~~
amitport
In the aviation industry pilots rarely get sued personally. IMO, the issue is
more about legal system than it is about the medical one.

~~~
api_or_ipa
If a pilot makes a mistake, he'll either die or lose his licence. Either way,
his life is ruined.

~~~
samirm
No it's not. Career =/= life.

~~~
jessaustin
Most pilots would feel pretty bad if they survived a crash that was fatal to
their passengers.

------
projektfu
One of the issues I've seen in implementing checklists is actually the urge of
people to put extreme detail into the checklist and people not putting items
in a reasonable order. If you look at the referenced checklist
([https://apps.who.int/iris/bitstream/handle/10665/44186/97892...](https://apps.who.int/iris/bitstream/handle/10665/44186/9789241598590_eng_Checklist.pdf))
it is a very approachable list that acknowledges good skill in the people
involved. Note that the "before patient leaves" checklist mentions the sponge
count but the pre-incision checklist does not. That's because a sponge count
is simply part of the job of an instrument nurse and something they always do
when they open a pack of sponges.

It's also hard to insert checklists into established procedures. One thing you
could do is attach them to important parts that are not allowed to be used
until you read the checklist. For example, you could refuse to unwrap the main
surgical pack until the pre-incision checklist is followed. Pharmacy could
wrap the anesthetic induction drug in the first checklist. The surgeon could
be responsible for signing the final checklist in order to get paid.

Keep checklists simple, use them every time. Put them in places where they
have to be used.

~~~
specialist
Wise cautionary note. Use the right tool for the job.

Back when we used to burn "golden" CD-ROMs for releases: Our checklists were
getting too unwieldy, we were still making mistakes.

So I started a Go/NoGo process, aka Roman Evaluation. Any one could stop the
release for any reason. We'd fix the problem(s) identified, try again the next
day.

(Of course, we fed each release's results back into process during the post
mortems.)

~~~
pradn
I haven't heard of the term "Roman Evaluation". Where does it come from?

~~~
specialist
Huh. Because we used thumbs up or down, we called it Roman Evaluation. But
that's probably wrong. Releases required unanimous approval. aka blackballing
[https://en.wikipedia.org/wiki/Blackballing](https://en.wikipedia.org/wiki/Blackballing)

------
michaelt
And here is the checklist [1]

These seem like very common-sense things to check - Is this the right patient?
Are the instruments sterile? Have we counted all the surgical equipment after
the procedure?

[1]
[https://apps.who.int/iris/bitstream/handle/10665/44186/97892...](https://apps.who.int/iris/bitstream/handle/10665/44186/9789241598590_eng_Checklist.pdf)

~~~
koala_man
Thanks, I can't believe this wasn't in article. The BBC might need a checklist
of their own.

~~~
tgsovlerkhgsel
1\. If the article is referencing a document, video, or picture, is it
linked/embedded?

[ ] Yes [ ] Not available [ ] Not applicable

2\. If the document refers to a third party report, is it linked?

[ ] Yes [ ] Not available online [ ] Not applicable

3\. Are background sources linked to high-quality, external sources?

[ ] At least 3 links present [ ] We sat there for 1 minute and couldn't come
up with anything that needs linking

4\. Are needless generic internal links to category/tag pages etc. removed?

[ ] Yes

------
PhaedrusV
.... They haven't been using checklists? I've been getting so upset at the
medical community recently. Pilots solved most of these problems decades ago.
We've been trying to help them figure out these tools that we developed to
save lives, but it seems like things are only changing one funeral at a time.

~~~
dsfyu404ed
"500yr of progress being held back by 500yr of tradition" is highly applicable
to the medical profession. There's a lot of arrogance floating around the
medical profession as well that tends to put a damper on anything that might
reduce human error.

Surgeons don't need checklists because they don't make mistakes, unlike those
filthy three dimensional bus and truck drivers. /s

~~~
throwayEngineer
This explains why the American Medical Association is a top lobbyist.

Instead of adapting, they legislate.

And the fantasy that Physicians are unfailing experts leaves you after a you
regularly interact with them.

~~~
justaguyhere
I have had the same experience in other countries too, not just the U.S

Medical profession really comes across as arrogant and know-it-all, at least
in my experience

------
wonder_er
The potential benefit of having checklists is enormous, and people's lives are
on the line.

Many people rightfully ask

> Why has this not been adopted everywhere _yesterday_?

A book I read a few years ago might have the answer.

_Catastrophic Care: How American Health Care Killed My Father—and How We Can
Fix It _ [0]

Here's the description, to evaluate if you want to give it a read:

> In 2007, David Goldhill's father died from a series of infections acquired
> in a well-regarded New York hospital. The bill was for several hundred
> thousand dollars--and Medicare paid it.

> These circumstances left Goldhill angry and determined to understand how it
> was possible that world-class technology and well-trained personnel could
> result in such simple, inexcusable carelessness--and how a business that
> failed so miserably could be rewarded with full payment.

> Catastrophic Care is the eye-opening result.

> Goldhill explicates a health-care system that now costs nearly $2.5 trillion
> annually, bars many from treatment, provides inconsistent quality of care,
> offers negligible customer service, and in which an estimated 200,000
> Americans die each year from errors. Above all, he exposes the fundamental
> fallacy of our entire system--that Medicare and insurance coverage make care
> cheaper and improve our health--and suggests a comprehensive new approach
> that could produce better results at more acceptable costs immediately by
> giving us, the patients, a real role in the process.

[0] [https://www.goodreads.com/book/show/13642523-catastrophic-
ca...](https://www.goodreads.com/book/show/13642523-catastrophic-care)

edit: formatting

~~~
nwah1
If we had a medicare-for-all system, we could provide some economic discipline
by having high deductible plans, even if those plans are completely covered by
a government-funded HSA plan of equal value. As long as the HSA could be
withdrawn for retirement if unspent.

We also need transparent pricing and reviews. Sites like ZocDoc are trying to
fill the niche of something like Yelp but for doctors. There's lots of easy
low hanging fruit here.

------
kasperni
Here is a link to the actual checklist:

[https://apps.who.int/iris/bitstream/handle/10665/44186/97892...](https://apps.who.int/iris/bitstream/handle/10665/44186/9789241598590_eng_Checklist.pdf)

I'm a bit perplexed that something so simple, can reduce post surgical deaths
by a third.

~~~
alexpotato
Atul Gawande explains in great detail how simple checklists can have big
impacts.

For example, why would you need everyone in the room to say their name and
what they do?

Simple: everyone is wearing a mask and often surgical scrubs that are the same
color. By having everyone say "Hello, my name is Dr. Jones and I'm the
anaesthesiologist" you can quickly determine who is the person to direct
questions to about the patient being under.

It gets even crazier when you hear stories about doctors going into the wrong
operating room (especially at bigger hospitals where there are several ORs). A
simple "State who you are and why you are here?" costs very little and helps
avoid costly mistakes.

Another example: having a checklist allows a junior person (e.g. a nurse) to
challenge more senior people when they make a mistake.

Example without checklist:

Nurse: Dr, I think you forgot to do X.

Dr: I know what I'm doing, don't question me.

Example WITH checklist:

Nurse: Dr, you missed step #4.

Dr: I'm sorry, you are correct. We all agreed that was a necessary step and I
missed it.

As have others in sibling threads, highly recommend Gawande's Checklist
Manifesto.

~~~
IMTDb
Your example depends more on the personality (and mood) of the surgeon than on
the existence of a checklist.

Example without checklist: Nurse: Dr, I think you forgot to do X. Dr: Oh, you
are right, thanks a lot

Example with checklist : Nurse: Dr, you missed step #4. Dr: I have done this
list every day for the past 15 years, I know I ddid not forget anything, don't
question me

~~~
alexpotato
You are correct that there are surgeons etc that would reply in the negative
no matter what was said.

My understanding is that if the checklist empowers, say, 5% of the nurses to
speak up and 5% of surgeons to acknowledge the error that is still a huge net
positive over thousands of cases.

My favorite small nudge example is pill bottles vs "blister" packs. Having
pills in blister packs has shown to have a significant effect on reducing
suicide as it makes it much harder to get the number of pills needed. Yes,
some people will still succeed but there is a segment of the target population
who will give up after a couple pills.

~~~
mnw21cam
I have a prescription that means I take eight pills in one go. And they are
provided in blister packs. It's really annoying. I can see that this is a
thing.

------
quizme2000
"The Checklist Manifesto" by Dr Atul Gawande details how resistant to change
Medical Professionals can be to procedure. I thought it was hyperbole until I
sat in on a certification training for a hospital group and the toxic cloud of
chatter about not changing anything because it didn't make a difference was
jaw-dropping.

------
thinkcontext
The article (really a blurb) mentions Atul Gawande, he's written extensively
and accessibly on how to improve healthcare both cost and quality. I can't
recommend his writing enough, especially his New Yorker articles where he
tackles subjects like unnecessary care, electronic health records, doctor
training, etc.

Article on checklists in the New Yorker

[https://www.newyorker.com/magazine/2007/12/10/the-
checklist](https://www.newyorker.com/magazine/2007/12/10/the-checklist)

------
jpollock
Given the number of surgeries/year in Scotland (2009/2010 20,048) [1] the
checklist saved:

Death rate after fix: 0.46% Number of deaths after:93

Death rate before fix: 0.46/(1-0.37) = 0.73% Number of deaths before: 147

Number of lives saved per year: 54.

[1]
[https://academic.oup.com/bja/article/119/2/249/4049141](https://academic.oup.com/bja/article/119/2/249/4049141)

------
jessaustin
Checklists are the reason that California has 4.5 maternal deaths per 100k
live births, while USA as a whole has 26.4. [0] If hospitals cared about this
sort of thing, there wouldn't have to be state regulations for this. If states
besides California cared about this sort of thing, they'd have the regulations
too.

[0] [https://www.usatoday.com/deadly-
deliveries/interactive/how-h...](https://www.usatoday.com/deadly-
deliveries/interactive/how-hospitals-are-failing-new-moms-in-graphics/)

------
Gpetrium
It would be interesting to see the implementation of an Alexa/Google' smart
speaker & tablet system to provide support to doctors & nurses. For example:

Doctor - "Smith, please provide checklist for Septal Myectomy"

Smith - "Confirming list for Septal Myectomy?"

Doctor - "Yes"

(Smith raises first point)

Doctor -"Check"

(Smith raises other points until the end of the list)

Smith - "You have completed the checklist for Septal Myectomy, please review
it on the screen if you so desire. Is there anything I can help you with?"

Doctor - "Thanks Smith, no need for anything else"

I would be eager to support a project that would provide this kind of support
to doctors and other professionals.

------
rb808
I'm not convinced about using a lot of checklists. I have no doubt when
checklists first come in everyone follows them and there are some measurable
improvements.

The problem I have twofold. A few years down the road will people still really
follow the checklists religiously, or quickly just fill out the boxes.

The second part is people's jobs get dumbed down by this, I'm sure we've been
in some situation where there is a structured system which you have no
control, you just fill out forms, its disempowering so you learn not to think,
just do your part of the system and hope it turns out OK. Its where
bureaucracy and red tape starts. I've quit jobs like that because I found it
demoralizing.

Will be interesting if there was a follow up 5 years later.

EDIT: Didn't you get the memo about your TPS reports? That is what I'm trying
to avoid.

~~~
tonfa
The checklist was given elsewhere in the thread:
[https://apps.who.int/iris/bitstream/handle/10665/44186/97892...](https://apps.who.int/iris/bitstream/handle/10665/44186/9789241598590_eng_Checklist.pdf)
it really doesn't strike me as something that dumbs down the job...

~~~
wccrawford
"dumbs down" is such a loaded phrase, but I'd argue that it's accurate here
and most other places it's used. Anything that makes something easier is
dumbing it down.

However, I _want_ it "dumbed down". I want it to be easier to prevent
mistakes. I want smart people to use more of their brainpower on things that
can't be solved by some words and boxes on paper. If the surgeon is thinking
about the surgery instead of what he might have forgotten about the pre-op,
that's _good_ , IMO.

~~~
rb808
> If the surgeon is thinking about the surgery instead of what he might have
> forgotten about the pre-op, that's good, IMO.

Agreed. The only issue is that if the surgeon isn't thinking about the surgery
because he's still doing all the routine paperwork.

------
richev
I create short-lived checklists all the time. For an up-coming food shopping
outing, or a to-do list for the weekend.

My favourite ones are for vacations... My wife and I will be taking our son
(who will be 5 months old at the time) on his first trip that will require
long haul flights (Australia - Vietnam - UK) so I'm currently working on a
checklist for what to have in our hand luggage, and a separate one for the
hold luggage. For me, it's part of the looking-forward aspect to such a trip,
plus there are lots of things that we really don't want to forget, or run out
of.

And anyone who's scuba dived will be familiar with the three item checklist
that forms part of the pre-dive "buddy check".

* B A R (buoyancy, air, releases) in the UK

* A B C (air, buoyancy, clips) in the US and probably elsewhere

A potential life saver!

------
Ensorceled
For 30 years, every place I've gone to, I've implemented release process and
release day checklists because they didn't exist. I've experienced push back
every time: "We haven't needed these before.". At all of these places, release
issues were always "bad luck". All of my teams have acknowledged these were
awesome and reduced release day stress.

I completely understand why this took effort to get implemented and why it
seems obvious in retrospect.

~~~
camnora
Do you have examples or a blog post that covers some of the checklist items? I
find this interesting.

------
KboPAacDA3
The saga of how this checklist came into existence is detailed in Dr.
Gawande's book The Checklist Manifesto.

~~~
ahaferburg
Or the much shorter article
[https://www.newyorker.com/magazine/2007/12/10/the-
checklist](https://www.newyorker.com/magazine/2007/12/10/the-checklist)

------
feederico
Should you want to know more about checklists, here's the very Atul Gawande
[https://youtu.be/dfl8Xt8W09A](https://youtu.be/dfl8Xt8W09A)

------
rmmm
Freakonomics Radio had Dr. Atul Gawande on a year ago (April 2018) and
discussed medical checklists among other things.

[http://freakonomics.com/podcast/atul-
gawande/](http://freakonomics.com/podcast/atul-gawande/)

------
caboteria
I started using a checklist for my motorcycle track days a few years ago when
I _almost_ forgot the key to my bike. I remembered as I was pulling out of the
driveway. Now I've got a thorough checklist, and a track bike that doesn't use
a key.

------
anderspitman
I've seen a huge personal impact adopting principles from David Allen's
Getting Things Done methodology, which in some ways is simply a checklist
management system. As others have mentioned, it's not just preventing me from
forgetting to do things. Capturing my thoughts and intentions externally
reduces stress and frees my mind to have more new thoughts. My creativity has
skyrocketed since I started writing down every project/product idea I have,
and adding to them over time. Currently using Trello (which works great for
this), but eventually I'd like to switch to something open source or make my
own system tailored to my needs.

~~~
indiandennis
I used to use trello too, but I switched to notion, which is more free-form
and let's you organize things how you want. Sounds like what you might be
looking for.

~~~
anderspitman
I've seen it mentioned. I'll take a look, thanks

------
MarkMc
A great book on this subject is The Checklist Manifesto [0]. An interesting
point made in the book is that checklists help to correct the subtle
psychological problems that occur in an operating theatre. Without a checklist
a nurse who sees a potential problem might be hesitant to halt the procedure
when the surgeon is ready to start. But with a checklist the surgeon must get
explicit permission to begin from the nurse who is performing the checklist.

[0] [https://www.amazon.com/Checklist-Manifesto-How-Things-
Right/...](https://www.amazon.com/Checklist-Manifesto-How-Things-
Right/dp/0312430000)

------
prennert
It is fantastic to see this pan out in real life. I read the checklist
manifesto by Atul Gawande who helped to author the WHO checklist. It really
one of these mind expanding books that everyone should read. I have seen below
comments that ask why checklists are not standard even though they were
pivotal in reducing flight accidents. The reason is that knowledge is often
siloed, and people tend to overestimate themselves. How many checklists are
you using at work? If none, ask yourself why, and if they could be helpful.

The book also talks about the design of checklists which is not trivial at
all.

------
turc1656
The article is short so doesn't really delve into what happens after those
deaths - specifically investigation into cause or the legal ramifications.

I was hoping to get that info because the first thing that popped into my mind
was that people are/were apparently dying due to unnecessary reasons if a
simple checklist prevents 37% of surgical deaths. If that's the case, the only
way I could imagine classifying those deaths would be "gross negligence" and
therefore not subject to the protections of the legal agreements you sign
before surgery.

~~~
DanBC
I can't talk about Scotland because they have a devolved system and I have no
idea how it works up there.

I can talk a little bit about England.

There are two main ALBs (arms length bodies) that will be involved: NHS
Resoulation (the organisation that handles legal cases) and NHS Improvement
(the organisation that handles QI work). NHS England and NHS Improvement are
merging and I don't know what the new name will be. NHS Resolution used to be
called NHS Litigation Authority.

[https://resolution.nhs.uk/](https://resolution.nhs.uk/)

[https://improvement.nhs.uk/](https://improvement.nhs.uk/)

The information that NHSi has about "Just Culture" is here:
[https://improvement.nhs.uk/resources/just-culture-
guide/](https://improvement.nhs.uk/resources/just-culture-guide/)

If you have a look at this flow-chart you can see that they're trying to find
out if an incident that caused harm was deliberate, grossly negligent, caused
by wider system failings, etc.
[https://improvement.nhs.uk/documents/2490/NHS_0690_IC_A5_web...](https://improvement.nhs.uk/documents/2490/NHS_0690_IC_A5_web_version.pdf)

If you have a look at NHS Resolution's page about learning from harm you can
see that they're keen for healthcare professionals to 1) Say sorry, 2) explain
in full what went wrong 3) Explain how that's going to be prevented in future.
[https://resolution.nhs.uk/services/safety-and-
learning/](https://resolution.nhs.uk/services/safety-and-learning/)

This expands upon a legal duty of HCPs and NHS Trusts in England: the Duty of
Candour.

Here's the advice for doctors: [https://www.gmc-uk.org/ethical-
guidance/ethical-guidance-for...](https://www.gmc-uk.org/ethical-
guidance/ethical-guidance-for-doctors/candour---openness-and-honesty-when-
things-go-wrong/the-professional-duty-of-candour)

And nurses: [https://www.nmc.org.uk/standards/guidance/the-
professional-d...](https://www.nmc.org.uk/standards/guidance/the-professional-
duty-of-candour/read-the-professional-duty-of-candour/)

And other registered healthcare professionals: [https://www.hcpc-
uk.org/assets/documents/10003f72enc07-dutyo...](https://www.hcpc-
uk.org/assets/documents/10003f72enc07-dutyofcandour.pdf)

And organisations: [https://www.cqc.org.uk/guidance-providers/regulations-
enforc...](https://www.cqc.org.uk/guidance-providers/regulations-
enforcement/regulation-20-duty-candour)

If a patient does decide to sue I think they can only recoup their actual
losses. I think we don't have punitive damages in England.

------
wastra
I am an anaesthetia doctor. There is, in fact, only mixed evidence of
checklists actually helping in various health systems around the world. At a
national level, Scotland began using checklists, but the whole health system
and population is always in flux, so attribution of such a big change just to
checklists is bold. It may also be that checklists do (temporarily?) improve
broken or highly resource constrained peri-operative care: but this leaves
open the question as to whether correcting underlying
staff/morale/equipment/logistic problems would have, or should, play a role.

Checklists I have seen used during my career are often rushed through, with
more time usually being spent appropriate to the complexity of a situation.
Local culture will strongly impinge on effectiveness of (yet another?)
checklist. The safety culture in medicine is improving dramatically, but there
is tension between protocolizing everything into checklists, and
individualizing care to each patient. AI will be part of the solution to this.

An important checklist commonality in medicine is the request that _anyone_
should speak up if they think something is wrong. In analyzing situations
where patients were harmed, e.g. wrong side surgery, it is common to hear that
someone, a nurse, a technician, did notice, but was not empowered to speak up.
As a doctor, I am used to the power to speak up and act, but I value others'
eyes in many situations. More complex and highly dynamic medical situations
will always require the attention, knowledge and skill of those involved.

------
cs02rm0
The checklist seems to be here:
[https://www.who.int/patientsafety/topics/safe-
surgery/checkl...](https://www.who.int/patientsafety/topics/safe-
surgery/checklist/en/)

As a software engineer, I'd hope this was done in software, where it could be
trivially filled in by multiple people, checked across the organisation, not
go missing or get drinks spilled on, etc.

Knowing the NHS south of the border, I assume it's not.

~~~
fiftyacorn
Papers probably easier - these NHS software projects always end up disasters

------
jillesvangurp
Checklists are great; checklist bureaucracy not so much. Sometimes such
bureaucracy is necessary.

For example when you are flying a cesnna 172 from the nineteen sixties, you
are basically flying a glorified lawn mower. It has procedures for starting
up. Not following those will lead to disasters like your engine quitting, or
worse self destroying. Hence a lot of checklists in aviation tend to be about
engine management. These are important, they keep you alive and save you from
high maintenance cost and accidents.

Cars used to be similarly complicated but these days you simply turn them on
and drive. Likewise, checklists for modern airplanes that have elaborate
engine management software tend to be a lot shorter and also focus more on
other things (check the amount of fuel).

Checklist are easy to automate for a lot of use cases and doing so increases
safety because computers are a lot better at checking lots of things than we
are. After checklists become part of your process and increase your
effectiveness, automating them can increase your efficiency.

The analogy in software engineering is replacing release processes with CI and
CD. It used to be that people were enduring such things as commit freezes,
meetings about blocking issues, go/no-go decisions, etc. This could last for
weeks or months. Also the process of actually creating release artifacts and
publishing those was a lot of work. These days, some systems release whenever
a change is merged to a particular branch. All the checks around this are
automated (tests pass). The entire process of releasing can be automated.

------
macspoofing
Checklists are the foundation of a proper quality system even in software
development. I manage a team of programmers that develops a regulated product
in healthcare (Class 2 Medical Device) - we use checklists extensively
throughout the development cycle, in release planning, release kick-off,
feature kick-off, in design reviews, in risk/hazard meetings, to track in-
house and external validation, and post-release activities.

I'm surprised how little checklists are used in software development. In our
application, checklists track even simple things. Suppose you're adding some
new feature we have a checklist that tracks related activities such as:

\- Does it need a toolbar button?

\- Does it need a keyboard/mouse input biding?

\- If so did you add a keyboard binding to the default configuration list?

\- If so did you add the binding information to the user help file.

\- Should it be exposed in Mobile Native App?

\- Should it be exposed in Mobile HTML App?

\- Should it be exposed in HTML App?

\- Was the button label localized?

\- Was the identifier added to the toolbar mask list?

\- Does it need to be added to the context menu list?

\- Does the behaviour need to work with Reset?

\- Does the behaviour needs to work in a collaborative session?

\- Does the button need a feature flag?

etc.

It's a quick list that we can get through during feature kick-off before
unpacking commercial requirements and starting a sprint and during final
validation to make sure al the i's are dotted and t's crossed.

------
mmaunder
Does this include the new(ish) timeout procedure? Docs and nurses will take a
beat before surgery to say the patients name, what the procedure is and I
think one or two other very basic things. This has been done for a few years
now in the USA and I find it fascinating. So basic in such a sophisticated
space and I have heard it has had a profound impact on patient safety.

Any surgical staff around to tell us more?

~~~
DanBC
I'm not surgical staff. The checklist does include this discussion phase.
Here's the English version: [https://improvement.nhs.uk/documents/450/SFHFT_-
_Invasive_Pr...](https://improvement.nhs.uk/documents/450/SFHFT_-
_Invasive_Procedure_Policy_-_Appendix_A_-_Surgical_Safety_Checklist.pdf)

------
kentosi
I love prepared checklists! It's the ultimate productivity hack for me. I
spend time upfront preparing the list, and then I go into auto-pilot everytime
I use it. No stress, no cognitive load, no questioning whether you've
forgotten something.

I use one for travel (did I pack a neck pillow?), night-time (did I pack my
gym clothes for tomorrow?), and recently for the gym (what workouts am I doing
today?)

------
_ph_
Several times in the discussions here I read about the checklist in question:
but these are obvious items, why do they need to be checked? I think that is
the very point of check lists: not to miss actions, because they seem to be
trivial/obvious. Be it because the stress levels are high or because one is
focussed on the "real problem at hand". In a sense, the more
intelligent/capable/experienced you are, the more you are at risk of missing
something as you are focussed on the big picture.

As a software developer, while not having checklists as printable documents, I
highly appreciate the checklist approach. This can take several shapes. When
doing a software release, I perform the necessary steps always in the same
order. This makes it easier to correctly perform everything needed. And of
course I check the result of every step for the expected result.

Checklist-like approaches can be even very helpful when debugging issues. I
often enough get to resolve "the software doesn't work" like issues. And of
course, there is no obvious reason, like a meaningful error message or stack
trace. To debug this kind of issues, I start with simple and trivial things.
While not a static list - the cases are too varying for that - I tend to start
with asking and checking very basic questions, like: is there enough free disk
space? Repeating the steps which, according to the bug reporter, lead to the
issue. At each action taken, verify that any observeable result matches the
expectation, even if those actions are not close to the bug. This approach has
usually two outcomes. Either a very trivial explanation for the problem is
found, because some seemingly trivial step fails, or at least, I know, that
all the things tested are note related to the problem. Excluding a wide range
of possible problems can be surprisingly helpful in narrowing down the actual
problem.

------
Razengan
Any recommendations for good apps for routine checklists (i.e. repeated
daily)? (preferably cross-platform and without subscriptions.)

~~~
kristianp
Before checking in code:

* have the unit tests been built and run?

* have I reviewed all changes and removed commented out code, tidied up?

Edit: oh, you meant apps. I read your comment as asking for good items for
checklists.

------
samstave
The "checklist manifesto" is a staple in American Healthcare... And when I was
consulting on hospital builds and go-live... this was the methodology we used.

[https://www.amazon.com/Checklist-Manifesto-How-Things-
Right-...](https://www.amazon.com/Checklist-Manifesto-How-Things-Right-
ebook/dp/B0030V0PEW)

------
pithymaxim
Checklists are probably good but looking at the actual paper[0] I don't think
we can conclude "a third" with much confidence. The mortality rate for
surgeries was already declining--the argument is that it declined faster
during the implementation period (Fig 2; 2008-2010). Also it appears the types
of admissions changed a lot during the same period based on the stark
difference between Fig 1 (unadjusted) and Fig 2 (adjusted).

I'm surprised that the researchers didn't use better data or variation (e.g.,
hospital-level mortality or the timing of the rollout) to strengthen the case.
So much can be lurking beneath annual country averages...

[0]:
[https://onlinelibrary.wiley.com/doi/full/10.1002/bjs.11151](https://onlinelibrary.wiley.com/doi/full/10.1002/bjs.11151)

------
spenrose
The study:

[https://onlinelibrary.wiley.com/doi/full/10.1002/bjs.11151](https://onlinelibrary.wiley.com/doi/full/10.1002/bjs.11151)

------
gfiorav
I'm an aviation enthusiast and have started developing check-list for
maintainers of the software I develop at work. I hope it will reduce cognitive
stress in situations of on-call.

------
docker_up
Doesn't this indicate some sort of malpractice in Scotland? I would think that
forgetting important procedures leading to death is the definition of
malpractice.

~~~
matthewmacleod
I'm not really sure what your point is. Ultimately, any kind of negligent
behaviour would be "malpractice", but that's not something that can be
completely eliminated. Mistakes always happen, regardless of care or attention
paid; it seems like the focus should be to develop systems which can minimise
their occurrence, minimise the severity of them if they do occur, and help to
provide information that can reduce recurrence.

I find the approach of things like rail and air accident investigations to be
really useful. The goal for the investigation of any accident should not be
about apportioning blame, but understanding why accidents happen and how their
occurrence can be effectively reduced or eliminated.

------
coob
I can recommend the book Black Box Thinking [1] by Matthew Syed. It covers how
not only checklists but also the learning culture that produced them can be
applied to other industries and areas.

[1] [https://www.amazon.co.uk/Black-Box-Thinking-Surprising-
Succe...](https://www.amazon.co.uk/Black-Box-Thinking-Surprising-
Success/dp/1473613779)

------
monocasa
Going one step further, the Japanese train industry has a concept called
"pointing and calling" where they literally point at the thing that should be
complete and call out the task. It noticeably improves completion of these
tasks.

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

------
tvchurch
This makes me think of Charlie Munger's insistence on checklists:
[https://www.amazon.com/Poor-Charlies-Almanack-Charles-
Expand...](https://www.amazon.com/Poor-Charlies-Almanack-Charles-
Expanded/dp/1578645018/ref=sr_1_1?keywords=Poor+Charlie%27s+Almanac&qid=1555515945&s=gateway&sr=8-1)

------
hyperpallium
Checklists: boring and tedious!

To catch errors, I started double-checking math problems, by generating a
checklist on the spot.

But I also _made_ fewer errors, and developed more intuition. I think checking
itself was a deeper practice; and also gave an overview of the task (less
cluttered by detail) that helped me make connections at a higher level.

Checklists: _insightful_ and tedious!

------
skorbenko
Atul Gawande wrote a fantastic book[0] on the topic.

[0]: [https://www.amazon.com/Checklist-Manifesto-How-Things-
Right-...](https://www.amazon.com/Checklist-Manifesto-How-Things-Right-
ebook/dp/B0030V0PEW/ref=sr_1_1?keywords=checklist+manifesto&qid=1555516277&s=gateway&sr=8-1)

------
zeristor
Perhaps they could pick up the Japanese train drivers pointing and calling:

[https://www.youtube.com/watch?v=9LmdUz3rOQU](https://www.youtube.com/watch?v=9LmdUz3rOQU)

Referring to things in multiple ways is supposed to have a more thorough
confirmation, although not a good idea to point whilst wielding a scalpel.

------
qubyte
A few others have mentioned it, but this reminds me of shisa kanko, the
pointing-and-calling system used in Japan.

[https://www.atlasobscura.com/articles/pointing-and-
calling-j...](https://www.atlasobscura.com/articles/pointing-and-calling-
japan-trains)

------
edpichler
For people interested in this, I strongly recommend reading the Checklist
Manifesto
[https://en.wikipedia.org/wiki/The_Checklist_Manifesto](https://en.wikipedia.org/wiki/The_Checklist_Manifesto)

A checklist is a practical tool to document processes.

------
tigerlily
Banana boxes are fantastic. Even so, checklists help me audit my adventure
inventory to make sure I have everything I need before I set off. I even use
checklists for making sure the apartment I'm about to rent has everything in
order. Things like check under the sink for leakages.

------
danjc
Does anyone else think that a nearly 1 in 200 chance of dying following
surgery is very high? I'm not sure I'd want surgery for a non-life threatening
condition if the chance of death is that high.

~~~
tgsovlerkhgsel
I suspect your chances to die from surgery for a non-life threatening
condition may be a lot lower than 1 in 200, while your chances of dying if you
are 80 years old, on the brink of death, with multiple different conditions at
the same time, and having difficult surgery.

------
taoufix
This reminds me of the Japanese railway employees pointing at things.

[https://www.youtube.com/watch?v=9LmdUz3rOQU](https://www.youtube.com/watch?v=9LmdUz3rOQU)

------
drumttocs8
That's terrifying. Thousands and thousands of lives have been lost simply
because we were forgetting to do the right things? And we created a process to
fix this in... 2019?

~~~
DanBC
The process was introduced in 2008.

This news is that we've now run research across an entire country (Scotland)
for the surgery carried out between 2000 to 2012 to find out how much harm has
been prevented.

------
quickthrower2
We had death by Powerpoint recently on HN. Is this life by Excel?

------
ste1n
Great interview with Dr. Gawande here: [https://fs.blog/atul-
gawande/](https://fs.blog/atul-gawande/)

------
ausbah
can anyone comment about applying this "checklist process" to software
development? has anyone used it to help with debugging, testing, merging,
etc.?

~~~
CGamesPlay
I've used it in situations where writing automated tests would have been too
difficult compared to running through a checklist each time. I made a web game
based on a variant of Chess, and I would run through the checklist before I
committed to verify I hadn't broken anything.
[https://gist.github.com/CGamesPlay/1b3e150c5448c51fd6ea71ea6...](https://gist.github.com/CGamesPlay/1b3e150c5448c51fd6ea71ea684f5640)

------
barking
This is how fast food franchises work and is why you get a consistent
experience from them all. All the processes are documented and checklists
abound.

------
miguelmota
Checklists are great. Less cognitive load having to recall things. I use
Trello boards for maintaining my personal checklists. Recommend it.

------
WordSkill
I lived in Scotland for a decade or so. On the surface, the provision of
healthcare seemed good, and the media constantly tells you it is, but it
tended to fall apart once you needed it for anything serious.

I heard of the experiences from countless others and, sadly, encountered it
myself. As the patient, even though you are paying for the service through
high taxes, you are not seen as the customer. This leads to a certain sense,
when you do need a medical service, that they are doing you a favor, that you
are somehow the recipient of charity and should be grateful for what you get.

Decisions about what medicines or treatments are available are often
political, with certain high-profile conditions sucking up scarce resources at
the expense of others. The focus is very much on managing public opinion.

There are many situations in which cost considerations have a horrific impact
on lives. For instance, if there is a medicine which can prevent you losing
your sight, but it is expensive, you will be offered it only for your second
eye after you have lost sight in your first - the reasoning being that it is
only worth spending that much money to prevent total blindness, but sight in
one eye is enough.

If you think that your high taxes mean that your healthcare needs are covered,
think again.

There is also a deep-rooted coverup culture that circles the wagons around bad
doctors and poor processes. In my case, a ridiculous misdiagnosis had a real
impact on my life for over a year. The other healthcare professional only came
clean about it after the lead doctor had retired.

Again, you are not seen as the customer, as the one paying all their wages,
so, you should just shut up and be grateful for what you get.

I often laugh when I hear inexperienced American talk about how much better
the health system is in the UK. Sure, health insurance is expensive, but the
actual healthcare is leagues ahead of anything available via any sort of
national health service. Being recognized as the customer, with real rights,
is of pivotal importance in receiving the care you need, when you need it.

In fact, you often come across UK citizens with a rose-tinted view of the
National Health Service, but such opinions tend to change rapidly once you
actually need something more than an occasional General Practitioners
appointment. The whole thing is a cruel joke.

~~~
acallaghan
> Being recognized as the customer, with real rights, is of pivotal importance
> in receiving the care you need, when you need it.

Except if your poor though right? Isn't that really the case?

In the UK we don't tend to ignore kids broken bones if they have poor parents.
No one goes bankrupt and ends up homeless for contracting an illness, or
having an accident at work.

We also spend less on our taxes towards the NHS than Americans spend on their
Medicare - and then you have to pay for private 'health care' insurance on
top, including all of the 'co pays' and whatever. It's a system that's rigged
against you. For the rich, by the rich, to make the rich richer.

Even if the top 1% of private healthcare is better in the USA, you're ignoring
the 99% of healthcare that isn't.

Most Americans just can't see the simple fact - many many other countries are
better at this than you are. This is a solved problem in many other developed
countries.

Universal healthcare simply benefits everyone in society, and does so purley
for the common good.

~~~
WordSkill
> In the UK we don't tend to ignore kids broken bones if they have poor
> parents. No one goes bankrupt and ends up homeless for contracting an
> illness, or having an accident at work.

Kids with broken bones are at the easy end of the scale. Most people, before
they have experienced serious, complicated, expensive health issues, have a
series of relatively positive experiences with the NHS in which they present
with a minor issue that is dealt with by in a satisfactory manner. The system
is optimized for that. This maintains the illusion that, through your taxes,
your health requirements are "covered".

This falls apart once you present with something more complicated. You might
be surprised at the extent to which people in the UK are pretty much abandoned
when they hit a certain point. I know of many cases in which people had to
find the money, somewhere, to buy vital treatment that the NHS was not willing
to allocate. This is no less brutal than what happens to the uninsured in the
US ... but ... the big difference is that UK residents are under the delusion
that they do not need to worry.

Again, my argument is not that the NHS is bad, or evil, or that it does not
sometimes do a good job. What I am saying is that, over your lifetime as a
whole, it costs more than good health insurance would while letting you down
badly when, inevitably, you encounter more serious problems.

The best way to help the poor is to improve the economy. A massive,
complicated tax system makes it particularly hard to hire people at the low-
end of the skill range. It is simply not worth it, and this will become
increasingly evident as workers continue to be replaced by technology.

The UK has ended up with a multi-generational unemployed class who are under
the illusion that everything will be taken care of "from cradle to grave".
Their personal agency has been almost entirely removed. Alcoholism, obesity,
diabetes and depression are at epidemic levels among the unemployed. We have
created the perfect storm and it is the poor who will bear the brunt of that.

------
stefs
while i don't contest the usefulnes of checklists ...

"... some of the largest population-wide reductions in surgical deaths ..."

_reductions_. but how does it compare using absolute rates? it's usually easy
to achieve good numbers when the baseline is sub-par (diminishing returns).

------
wazoox
In France, a surgery checklist is available since 2008 or 2009 but alas, it's
not mandatory.

------
agumonkey
2019, age of AI/ML .. checklist is the most impactful health improvement.
Interesting

------
tedmcory77
Dr. Gawande’s book “The Checklist Manifesto” can be life changing if properly
applied.

------
ggregoire
Not sure why people don’t do checklists for everything. Professionally and
personally.

------
bch
related early paper:
[https://www.nejm.org/doi/full/10.1056/NEJMsa0810119](https://www.nejm.org/doi/full/10.1056/NEJMsa0810119)

------
balthasar
Cut down post-surgical deaths by using this one weird trick.

------
externalreality
I have Dr. Gwande's book for years now.

------
ctingom
Is this checklist used in the United States?

------
externalreality
Didn't read article - [check]

------
madrox
I instituted checklists across team process and can't recommend it enough. Our
pull request process reduced subjectiveness in PRs and approval time. It also
seemed to improve the quality of what got through the PR process. We also had
them for deploy process, sprint planning, and a few other domain specific
areas. We had other teams give input, which helped with compliance challenges
like GDPR and COPPA.

------
bullen
What is the list?

------
dosy
Here's the actual 19-point checklist in English[0, pdf]

and other languages[1]

[0]:
[https://apps.who.int/iris/bitstream/handle/10665/44186/97892...](https://apps.who.int/iris/bitstream/handle/10665/44186/9789241598590_eng_Checklist.pdf;jsessionid=8AD52FAEB1F160A0AE7503FE60E01E0C?sequence=2)

[1]: [https://www.who.int/patientsafety/topics/safe-
surgery/checkl...](https://www.who.int/patientsafety/topics/safe-
surgery/checklist/en/)

