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Post-surgical deaths in Scotland drop by a third, attributed to a checklist (bbc.co.uk)
1036 points by fanf2 34 days ago | hide | past | web | favorite | 366 comments

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...

edit: formatting

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 As long as the HSA could be withdrawn for retirement if unspent.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.

Essentially they pay for procedures and not for outcomes. Imagine if we compensated plumbers that way.

Here is a link to the actual checklist:


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

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.

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

> 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

You're not wrong, but if the hospital policy is to follow checklists, then the doctor overriding it would have to answer some questions afterwards if something were to go wrong.

Presumably a review would occur, and the fact that the checklist was ignored could be used as 'evidence' against the doctor.

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.

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.

Nothing will stop someone who's disagreeable, assertive, non-conscientious AND given unchecked status from ignoring a step for capricious reasons.

But medical school is going to heavily select for conscientiousness (a personality trait that checklists work with), and also checklists are essentially another authority in the room.

So, yes, you could potentially have discussions over whether or not something has actually been done. But you aren't going to have discussions about whether it should be.

The solution to that is to have people have proper uniforms. Eg surgeons/doctors/nurses wear different color scrubs & hats or insignia for rank. It was like this in the old days.

A lot of airline-style cockpit resource management is being adapted for operating theatres, and it is a good thing.

If a junior person thinks that a senior person is about to make a terrible mistake, then the word "Stop!" should be used, along with the reason. That word will often make even the most arrogant person pause and think about what they are doing.

Humans can hold about 5-7 things in working memory. You'll note there are 22 items on that list + the headings of when to do them.

Expertise and practice makes some of those things automatic, but not enough to reduce it all below 5-7. Further, in any surgery there will be other things going on that require cognitive attention, decreasing capacity for other things.

Everything you can do to reduce cognitive overhead makes a process smoother.

I teach the LSAT. One section logic games (officially, analytical reasoning) tests precisely this cognitive load. Students must work with 4-6 rules + what the situation calls for on question.

The rules are impossibly simple. But, in the heat of things, students just aren't capable of working with that many items unless they create a structure using diagrams. And even seemingly tiny efficiencies have an outside effect on speed and correctness.

Don't forget that these surgeons are often tired busy and stressed, three factors that worsen performance. Having a clear list that says "do this now dummy!" massively helps keep you on track even when you're a wreck.

A lot of the time, people ignore over small, simple things because they either assume someone else already took care of it or that it's such an obvious thing that how could anyone not notice. The checklist forces you to actually look up and see that the extra blood needed for the surgery didn't show up or that one of the surgeons present is actually supposed to be in another OR.

It's like help desk asking you if it's plugged in. You may think of yourself as a technical person and that the problem is more complex like the driver isn't loaded or the monitor isn't properly configured but the problem could just be that you forgot to plug the video cable in. Just having those basic checks occur before anything can go wrong makes it so that when things do go wrong, time doesn't need to be wasted on going over the simple stuff or even worse, forgetting about the simple stuff and going down the wrong route.

In any profession most practitioners are bad at what they do. There's nothing magical about medicine that exempts that profession from this rule. If your mechanic can forget to refill the oil in your engine there's no reason to believe that your surgeon won't leave a knife in your abdomen. There will be by necessity bottom-tier doctors and the checklist helps bottom-tier doctors stop killing people.

Not just bottom tier... humans are very good at making simple mistakes. It's one of the things we do best. A lot of times the people who are rated as "good" or "great" are rated that way because the make fewer mistakes, not because of perfection.

I'm not. A clinician is a human, and as a human, they can be distracted, tired, hungry, or any number of things that can reduce their cognition leading them to miss something. A checklist reduces cognitive overhead and provides accountability (no way a clinician would remember if they did or didn't do a particular action days or weeks or months after the fact).

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

Because it didn't. It attributes the entirety of a decade long decline to the check list, which is obviously nonsense. I'm not saying that checklists aren't good, but they're not miracle workers.

They didn't just measure the difference and call it a day.


>The Scottish Patient Safety Programme (SPSP) is a national initiative which aims to improve in‐hospital mortality rates in Scotland. The SPSP was established in 2008 and had perioperative management, including implementation of the WHO surgical checklist, as one of its four key initial workstreams. This programme offered a systematic approach to improve patient safety across all hospitals in the country26.

>After testing, review and feedback from health boards across Scotland, the surgical checklist was included as one of the ten Patient Safety Essentials to be implemented across all health boards in Scotland37. The surgical checklist was not a stand‐alone intervention. It was, however, the only Patient Safety Essential that targeted surgical patients specifically during the interval studied37. Thus, the addition of the checklist to the other parameters within the SPSP may have contributed to the improvement in results observed in the present study.

>It is acknowledged that attributing causal links to the findings in population‐wide data set analysis is not possible.

What you said they didn't do is kind of exactly what they did. Yes, there is some attempts at hand waving, but it's silly to boil down the success of a large and multi pronged program to a simple checklist.

>It was, however, the only Patient Safety Essential that targeted surgical patients specifically during the interval studied.

That's hardly hand-waving.

That's exactly what hand-waving is. It's bad logic they use to support a conclusion that they then immediately hedge in the following sentence.

Here's the 10 safety essentials check list they are talking about:


If the checklist is responsible for all of the improvement in surgical outcomes then we can stop doing the rest of the stuff, right? No need to emphasize hand washing or sterile central line because the magic checklist will stop the infection.

Even if the checklist was responsible for all of the improvement in surgical outcomes that doesn't mean the other items don't have an affect anywhere else. And again, it's not hand-waving to suggest that the item that has the largest direct impact on surgical operations is mainly responsible for the reduction. There's a difference between you wanting a more thorough study and something being "obviously nonsense".

I agree. They don't control for external variables.


Here's a link to the study.

Please point out the parts of it that you find to be scientifically failing.

There's a valid point to be made that the original article implies a greater causal link than the study, but that isn't the study's fault, and it doesn't actually diminish the effect of the checklist in the process. Poor reporting on science is always a problem, and journalists typically use layperson phrasing in order to make the information more consumable.

"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.

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


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

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...

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.

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!

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.

Its where bureaucracy and red tape starts.

What people call bureaucracy is process that they follow without knowing why it's there. Every single rule in a business is there because something went wrong, and someone didn't want it to happen again.

The answer to bureaucracy is transparency. If you explain why a rule has to be followed people don't mind that there's a rule.

(You also have to regularly review the rules and get rid of ones that don't make sense any more, but that's much less common that you'd think.)

It must become a culture. In Japan, there's a culture in the public transport business (trains etc) of 'point and say' where each responsible crew member points at a target e.g. safe door open zone marked on the pavement, and says out loud that its correct or not. Its a physical reenactment of a checklist? Anyway it becomes second nature if its a physical act, not a check-the-box-on-a-form thing. So that's how they manage it not getting skipped/becoming just paperwork.

The checklist was given elsewhere in the thread: https://apps.who.int/iris/bitstream/handle/10665/44186/97892... it really doesn't strike me as something that dumbs down the job...

"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.

> 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.

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.

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

Add to the checklist: Can the patient survive the trip home? Based on a true story.

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

If I remember correctly, they had similar results (>30% improvements) with their pilot study in Michigan

Should you want to know more about checklists, here's the very Atul Gawande https://youtu.be/dfl8Xt8W09A

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


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.

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.

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.

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

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/...

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.

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.

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.

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.



The information that NHSi has about "Just Culture" is here: 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...

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/

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...

And nurses: https://www.nmc.org.uk/standards/guidance/the-professional-d...

And other registered healthcare professionals: https://www.hcpc-uk.org/assets/documents/10003f72enc07-dutyo...

And organisations: https://www.cqc.org.uk/guidance-providers/regulations-enforc...

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.

The checklist seems to be here: https://www.who.int/patientsafety/topics/safe-surgery/checkl...

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.

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

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.

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?


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.

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?)

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?

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...

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.

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

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.

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.


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

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...

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

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.

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.

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.

The English NHS was dealing with about one million patients every 36 hours. https://www.england.nhs.uk/ They were doing over 8 million surgeries per year when the checklist was introduced.

For 2016/2017 the summary of "never events" is here: https://improvement.nhs.uk/documents/2347/Never_Events_1_Apr...

There were 189 wrong site surgeries, and 114 retained foreign object post surgery.

That's not good enough, but it's not terrible.

The month by month data is here: https://improvement.nhs.uk/resources/never-events-data/

I have a comment about the regulatory framework (in England) here: https://news.ycombinator.com/item?id=19683366

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...

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.


This makes me think of Charlie Munger's insistence on checklists: https://www.amazon.com/Poor-Charlies-Almanack-Charles-Expand...

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!

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


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.

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

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

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.

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


For people interested in this, I strongly recommend reading the Checklist Manifesto https://en.wikipedia.org/wiki/The_Checklist_Manifesto

A checklist is a practical tool to document processes.

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


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.

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.

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

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?

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.

Great interview with Dr. Gawande here: https://fs.blog/atul-gawande/

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

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...

Automated tests are a checklist for when you refactor code: "The code is supposed to do A, B, and C. Does it still do those things?" If you practice TDD, the tests are just-in-time checklists for your implementation work.

The problem with relying on tests written after the implementation is that the checklist might be incomplete. If your checklist is incomplete, then you can't rely on it. Of course, even a highly disciplined practitioner of TDD cannot produce a test suite that is guaranteed to be complete and correct, but there is an enormous difference between a checklist that is adequate 50 % of the time and one that is adequate 95 % of the time.

Look for ways to avoid simply "going through the motions". Checklists (including TDD) are about avoiding making mistakes, not merely about noticing when you do make mistakes.

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.

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

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.

> 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.

> 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.

> 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

Exactly the same private healthcare is available to you in Scotland, if you chose to pay for it.

Yes, it is available, but the high levels of taxation - not just income tax but, also, a 20% tax on purchases - means that most families simply cannot afford that.

My argument is that people are _already_ paying but in a mandatory, indirect way, that removes their power as consumers and creates a situation in which the health services' prerogatives often differ from those of the patients.

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).

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

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

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

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

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

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

Is this checklist used in the United States?

Didn't read article - [check]

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.

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