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Hospital checklists are meant to save lives, so why do they often fail? (nature.com)
158 points by areoform 47 days ago | hide | past | web | favorite | 148 comments



I wonder. Does the Hawthorne Effect (https://en.wikipedia.org/wiki/Hawthorne_effect) contribute to the success of these checklist regimes?

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

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

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

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

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


> Airplane pilots use checklists. It's illegal to start the engines unless the approved checklist book is within reach of the pilot in command. In training it's drilled into us that the response to panic is: get out the checklist and follow it. It works.

Just some clarifications:

- It's not illegal to fly without a checklist under Part 91 (non air-carriers.) When I fly with military pilots, they use a flow for starting small airplanes:

http://fsims.faa.gov/PICDetail.aspx?docId=8900.1,Vol.3,Ch32,...

- the airplane manual is a book, and must be on the airplane. A checklist is a list, not a manual. The checklist can be electronic, as in the HondaJet.

- it's a good idea to follow the emergency procedures either from memory, or a checklist if there's time. Typically recovering from a stall or spin, or feathering a bad engine is done from memory, for example.

Source: commercially-rated airplane pilot.


Without any specific relevant experience in a hospital, isn't the most likely reason procedures fail that people are required to ignore/bypass parts of them constantly, rather than having them updated to match reality?

It seems so very obvious to me that any time you start asking, from a 40,000 foot level, why people can't follow simple instructions, the answer is going to be, not that they are all idiots, but that they are trained and required to ignore them selectively based on complex ever shifting criteria. That is basically what makes any job require a human and not a computer in the first place.

The more rigid you want people to be, the better the process has to be.


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

I think it's more likely that there is an immediate feedback loop to disregarding the checklist (i.e. the plane crashes and the pilot dies), whereas not washing your hands has a lot more delayed consequences in which the causation isn't readily known. I think this is the general problem with Outcomes Based Health - we have the stats to back up its effectiveness, but don't have the immediate feedback loops to promote it.


> In training it's drilled into us that the response to panic is: get out the checklist and follow it

I do this, and always teach others to do this, during incident response. The reason I think it works is it reduces your burden for making decisions during a stressful time. No matter who you are, how good you are at managing stress, or how experienced you are, you’ll almost always end up making worse decisions under pressure, so removing the need to make decisions as much as possible seems to generally lead to better outcomes.


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

Wash your hands 12 times a day for a week and you'll understand why people might not want to comply.

I want my doctor to wash his hands, but I can at least sympathize as to why he might not want to.


I have twin infants, a toddler, and work in a large office unrelated to medicine. I wash my hands on average 2 * 12 times a day, every day. It's my job to keep my family healthy. I suppose we are saying it is arguable that it's not the job of medical professionals to keep their patients healthy?

Hippocratic oath must be window dressing these days.


> I wash my hands on average 2 * 12 times a day, every day.

I simply don't believe you.

That would imply that you spend almost an hour per day washing your hands if you are following proper hand hygiene.

With twin infants and a toddler, I'm pretty sure you simply don't have that kind of time in a day.


When you say you "wash" your hands, do you do a full "apply soap to all sides of hands" every time?

Personally, I rinse my hands (i.e. with only water) pretty frequently, but only wash with soap when the occasion calls for it (when arriving home, when my hands are greasy, or after sitting at the toilet), which probably averages 2-3 times per day.

On a separate note, my family doctor used some kind of antiseptic and moisturizing lotion on his hands. He said the antiseptic would tend to dry the skin, so adding a moisturizing element to it was a genius idea and whoever came up with it was probably making millions.


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

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

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


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

If anything it’s existing shielding is the problem. The supply of doctors is artificially controlled and limited which means you can’t lower pressure through capitalistic approaches. Without fixing the supply (more doctors) or demand (don’t treat patients) issue these problems won’t go away.


The nursing shortage could be solved by hiring more. They overwork the few they hire so the MBA execs can buy nice things


> The nursing shortage could be solved by hiring more.

At least in Germany, there are massive amounts of open job postings for nursing and other care staff. The problem is that the wages are way too low, as the county/city-owned clinics have to adhere to the budget rule of maximum efficiency and minimum taxpayer subsidies (which led to massive outsourcing and other cost saving efforts in Munich [1]) and private-owned clinics are under financial pressure from their owners (you gotta make those 18% EBIT [2] somehow), while at the same time the amount of money that the public health insurances pay for procedures (fixed rates across the country) is not enough to cover these costs.

[1] https://www.kma-online.de/aktuelles/klinik-news/detail/staed...

[2] https://www.boeckler.de/117585_118442.htm


I meant specifically in the US market where one aspirin pill is billed to the patient as a $30 expense. Not in a country with free healthcare.


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

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

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


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


[flagged]


You still create a problem with prices since if everything is payed by the State, the pay is arbitrary


> You still create a problem with prices since if everything is payed by the State, the pay is arbitrary

No, it's no problem there. Raw materials / medicine, consumables, land, energy, work itself - everything has a price and thus a proper socialized healthcare system can account for everything, while putting patient outcome first and not money/profit.


Gloves are another one.. blows my mind.


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

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

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

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


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

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


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

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


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


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


> germ theory is still a struggle for doctors and hospitals

What do you mean by this? As written, it's total nonsense; germ theory is universally accepted.



The fact that patients get infected doesn't mean the hospital rejects "germ theory".


Then it should also apply to the use of contraceptives


Lack of contraceptive use does certainly have a delayed and inconsistent effect, but when the effect does happen it does so in a way that is far more visible and traceable than any disease caused by dirty hands.


I suspect that what made the culture of pilots change is that their own lives are on the line. That, and the fact that the guys flying the coolest fastest planes had commanding officers who could simply ground them if they didn't like it.


My father was an AF pilot for 20 years. I've never known a more conscientious and careful man.

One day he was going through the landing checklist, and was interrupted by a radio call. He resumed the checklist, then was told by the tower that he was attempting to land with the gear up. The interruption had caused him to skip that step on the checklist.

After that, whenever he was interrupted in a checklist, he started it over again.


I've been flying a somewhat large UAV lately, and inspired by the "real" aviators and The Checklist Manifesto, I put together a series of checklists. One for packing, one for pre-flight, and a mission-specific one for the day.

Early on I was pretty lax about following them, and inevitably something bad would happen. I'd forget to pack something and not realize it until I had driven an hour. I'd forget to check for loose bolts and lose one. Or I'd completely forget one of the objectives for the day and have to go back out.

I've tightened up my process quite a bit, and do exactly what your father does: if I get interrupted, I start over. It's mentally hard to do when I'm already feeling late, but I've come to the conclusion that that's exactly when I need to be more disciplined about it; that's when you forget things!


A little anecdote about the careful part. He flew ground attack missions in the Korean War. He didn't win any popularity contests on the ground. The leader for his squadron was one of the popular pilots. But when they were out of sight of the airfield, the squadron leader would radio my dad to assume the lead. He'd lead the squadron in and out, and when they got back near the base, he'd swap positions back with the actual squadron leader.

The reason was pretty simple. He'd take the time to pour over the maps and intelligence to find the safest route in and out, and they'd get back with the fewest holes in the airplanes.

I.e. when it counted, the squadron would entrust him with their lives.

I don't think it's possible to have a greater honor.


I've seen the same principle at work in a pretty different activity: rock climbing.

There's a well known story of one of the best climbers in the world getting approached by someone while she was tying the rope to her harness right before a climb. After a brief chat she proceeded to climb the route, lean back on the rope, and promptly plummet to the ground.

After being interrupted she had forgotten to finish tying a knot she had done thousands of times before. It's a good reminder to avoid letting yourself get interrupted in the middle of simple but extremely critical tasks, it's just so easy for the brain to skip over part of the process it knows well and consider it done.


Proper climbing procedure states that partners should check each other's harnesses and the rope to make sure they're connected to the same rope, the knots tied properly, buckles are double-backed, etc.

I had a similar incident many years ago where my partner only tied into one harness loop. Luckily it was in the gym and she wasn't on lead, but after that, I always make it a point to thoroughly check my partner's equipment.


Part of the problem is humans are all slightly different. Thus doctors need to understand the system because there is always something in the details that is unique and so the checklist needs to be deviated from. Once you are in the habit of this is different you quit using the checklist...

Checklists are very useful anyway because they let you focus on and remember the parts that are actually different. However when someone is highly trained it is easy to think you already know everything and not use the checklist.


Complexity probably has something to do with it. Every surgery is slightly different. So a reasonable size checklist would be missing enough items to kill the patient, and a complete one, the patient dies before you are 1% through it.


This is silly. Every surgery in the world requires "confirm which body part you are removing" and "make sure the scalpel is outside the patient before sewing up".


Yet people still cut off the wrong bits, leave things inside. Read this is you want to get mad: https://www.nj.com/hobokennow/2008/06/humc_suspends_doc_who_...

The doctor who did this is still practicing last I checked, as are the staff involved in covering it up, and the hospital he worked for was not informing patients of his history.

Another shockingly similar case: https://www.deseretnews.com/article/412903/HOSPITAL-SETTLES-...

Just two cases I remember reading about. Over a quarter million or more per year according to most sources.

Medical mistakes are the THIRD leading cause of death in the USA. Actually, conscientiously using a checklist to reduce that isn't too much to ask.


Medical mistakes happen and are very common, and I wouldn't be surprised if there were 250,000 per year.

But "wrong site surgery" is a tiny subset of medical error, and I'd be amazed if that was more than 1000 per year.

Most medical error is in the form of medication error. Medication error is very common, and I'd be surprised if it was as low as 250,000 per year. I'd guess that number was the number of people harmed by a medication error.

These errors are serious and we need to work to stop them, but we also need to put them into context. There are over 800 million physician office visits in the US per year. There are over 140 million ED visits per year.


Yet people still cut off the wrong bits, leave things inside.

The checklist is basically the physical equivalent of asking "are you sure you want to remove this limb?" every single time, and people will just "click OK" before long.


Aviation proves that untrue. Mostly people follow them. That some will not doesn't invalidate their worth. I am always confounded by people who argue everything isn't good enough, and then nothing ever changes as a result.


And these bits are put into checklist. In theory (and in my experience) they are performed at the beginning and towards the end of every operations. It’s the large decision space in between that struggles to be covered.


They have that last part. It's called the count.


You, Bluegill, and pmiller make good points about the complexity of humans and surgery.


I want my surgeon to know the procedure cold, but I would definitely not mind having a backup in the form of a checklist.


This is, I think, something that a lot of people who push back against checklists missunderstand. They feel that the checklist is meant as a replacement for their knowledge, skill and experience. An insult to their ability. But really it's just meant to help them not make very human errors of ommission or miss-sequencing that anyone, no matter how smart or experienced, can make.

Too many experts, in every field, stuggle with the idea that they too will make mistakes sometimes, and that this is perfectly normal no matter how good you are at what you do if you doo it often enough.


I struggle with this too— another way to think about it is that a checklist frees your mind to think of more creative/important things. By delegating the mundane to the checklist, your brain no longer needs to constantly track the basics and instead is free to focus on higher order thinking.

I find it takes a disproportionate amount of mental energy just to track even 5-10 items. Committing those items to a written list makes it easier for me to take that limited resource and be creative instead of constantly wondering if I completed step 3.


I like that way of phrasing it. I wish more people would think about things in this more positive light, but unfortunately whenever something like this comes up people start to get defensive.


On the flip side, I've seen with my two eyes, doctors watching a youtube version of the surgery before doing the real thing.

I wasn't in a position to verbally ask but it seemed common.


well, i heard in a podcast that surgeons -- not to pick on them but that was the example given -- don't have their own lives on the line and would likely ignore checklists. compared to say pilots.

yet, pilots make mistake too. examples were given when they rush and ignore the checklist or the second in command for example. rushing is usually the biggest mistake. and ignoring a lower ranking pilot is another big one.


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

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

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

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


I'm currently in the process of introducing checklists into a process, and the hardest part of the entire endeavor is giving the people who are using the checklist the power to modify them, and keeping other people from forcing the system to have chiseled into stone type checklists.

So far, the biggest contributor to 'checklist fatigue' among people using the system is from them not being able to modify the checklist to suit the task at hand. Checklists really need to be living documents, so errors and usability improvements can be made. The article does mention that the more proscribed from on-high the checklist was, the more the performance of the checklist was degraded.


100% agreed!

There is the attitude of "get over it" and follow the list - that does NOT work. What does work is exactly that - make the thing useful and people will actually love it. That means local adaption, ability to update and refine.

What works wonders is if you can introduce policy changes and improvements through the list. Ie, the list leads rather than follows and gets outdated.


> "The people using the checklists have little ability to change them or to improve them"

I was listing to an interview with the author of The Checklist Manifesto, Atul Gawande, and he cited this as one of the main reasons why attempts to use them fail in some organisations. He seems a big proponent of the people using checklists being the ones who should write and imporve them or at least be involved, and that they be kept short and focused. They shouldn't be stuffed with needless detail, they are not instruction manuals.

Checklists imposed from above without input from those who use them is just another version of beauracratic organisations imposing processes on people.


Also did some work ages ago with a safety critical element. Checklist fatigue is real.

Especially in govt compliance areas - a lot of folks have attitude of parent, get over the fatigue because this is "important". I once went to a presentation where they showed someone in handcuffs because they didn't follow the procedure. There are 100s of irrelevant items (yes - 8 track data standards compliance in some docs still) on some of these lists and people know it is total BS.

The authors of the article make a great point, local adaption and implementation. The checklists that work are carefully curated and honed. I currently work in a space with lots of checklists, and I take that approach, do we still need this item? Things change. If you make the checklist useful MUCH higher compliance. That means updating and refining it so it's the reference guide for what should be happening not an endless list of all possible things one could do.


I had a 138-page checklist during a software engineering gig. It was too ensure that my software was secure. While it was being approved (it passed, of course, the checklist being out of date and easy to meet), the legacy software (only fragments of which had source left) fulfilled the function. The legacy software was known to crash on constructed input that wasn't hard to guess.

The checklist had come after the software so any software that was better than legacy software couldn't displace it if it wasn't better in every way. So if you fixed one bug and attempted to deploy you couldn't because your new version had to pass the checklist.

Fascinating stuff.


There are solutions for that (e.g. point-and-say). Surgeons need to stop making excuses.


> They fail because of severe checklist fatigue

> checklists often leaves a lot to be desired.

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


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

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

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

Once it stops being that because it isn't perfect, it can easily increase mental complexity which requires more brain use and increases errors. That's the fatigue.

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


Keeping a checklist up to date is incredibly important.

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


The Messiah/God complex is a very real thing with MDs. It's dependant upon the enviroment and training, but a lot of them really do think that they are 'special' and that they have 'proved' themselves via the rigours of school and residency. Their sense of self is tied up into their job preformance. Like in other professions, if you 'attack' their job and their work, you are attacking them personally.


> The Messiah/God complex is a very real thing with MDs.

That's true with pilots, too, especially fighter pilots. But they rigorously use the checklists.

The pilots also know that many crashes have been traced to skipping an item on the checklist. For example, John Denver's fatal crash was due in part to failing to fuel the airplane before flight.


Fighter pilots aren’t going to get paid more if they cram in an extra mission by skipping steps.


It's also probably partially attributable to the fact that it's their own life on the line if they skip a checklist step like lowering landing gear.

That in combination with training. It's just the cultural thing to do, everyone uses checklists, a pilot from the moment they start training is always doing check lists.

It also helps that a checklist for a plane is always relevant where a checklist for a procedure is more variable.


Their career is also on the line, even if they live through the incident. Nobody wants to keep on a pilot who is careless with at $100m machine.


Yeah there's definitely a difference in the culture where checklists are the norm in aerospace where they're a new and developing thing in medicine.


Fighter pilots aren't in it for the pay. They often remark that they're amazed that people actually pay them to fly.

I'd forgive them for skipping the checklist if their airfield is under attack and they have to get their crates in the air or die on the field.


> aren't in it for the pay.

Nobody ever is. But if their contract negotiator ever opens with that line...


You're not going to cure the human condition. If checklist fatigue is a real problem, telling people to suck it up and do their jobs is not going to work. The process needs to be improved to account for check list fatigue, it's that simple. Be it read aloud each item before checking it off, have a secondary scribe confirming and checking it off, or any other improvement that minimizes the effect of the fatigue.


No matter how right you might be, "get over it" is not an effective way to change human behavior.


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

https://en.wikipedia.org/wiki/Pointing_and_calling


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


Both of you have fat fingers.


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


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


I got your back :)


Yes, I think it's frustrating that this is not widely adopted. The upsides are really obvious and the only downside (I guess?) is that it feels a bit awkward to do it before society has gotten used to it.

Another thing with obvious benefits I wish we would adopt from east Asia is wearing a face mask when having a cold to prevent infection those around you.


I imagine it also brings in a certain kind of kinesthetic memory into play, habits of movement rather than just habits of thinking.


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

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

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

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


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

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

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


Well, they only have to discover that their program halts, not all arbitrary programs so that's not quite the Halting Problem.


Key point is the last paragraph:

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


Official role for checklists in healthcare: save lives!

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

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

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

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


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

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

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


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


This is like Agile vs micromanagement in software dev.

The workaround for that is for the practicioners to have their own good checklists in addition.


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


> He believes he is above it

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


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


The problem is that it builds and establishes a habit that we will _accidentally_ engage in when we are tired, distracted, etc. This is where accidents happen, and why it is important to never consider yourself above the fray.

It’s not that anyone is always careless, it’s that everyone eventually has an off day, and in those off days our careful habits become careless ones.


He really isn't. He hits the rumble strips constantly when staring at his phone, and it only takes a second of inattention to kill someone. Being lucky so far isn't proof of competence. This attitude is the exact problem I was addressing in relation to the article...people thinking THEY are safe and others are the real problem and why we need checklists/rules.


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

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

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

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


There are some interesting experiments with hospital operation models in India that try to make it more like flight. Every patient gets the same surgeon and treatment, but people who pay more get nicer facilities (private rooms, less crowding, separate waiting area for family).

It's not an equal model, but it is more just than what we have in America today.

https://www.bloomberg.com/news/features/2019-03-26/the-world...


Yes, most private hospitals have this model in India where the same surgeons treat the highest paying and the lowest paying patients.

However, the price difference between the base pricing across these hospitals vary a lot and you tend to go looking for that famous surgeon who practices in a hospital where everything is more expensive (Narayana Health and a few others may be an exception).

Also, the other aspect of the airline industry which we should get in hospitals is sharing of best practices. The protocols and procedures which can be effective in saving lives should not be a differentiator, instead it should be standardised and made mandatory.

The differentiators should be non-medical as much as possible.

Of course, only the wealthy hospitals may be able to afford the latest equipments but the expertise of the medical staff and best practices are easily transferrable in a cheap way and shouldn't be guarded like an individual's or the organisation's IP


This meta problem, transferring best practices or as I like to call them "cultural technology" between groups of people, is literally the thing I'm working on right now.

If you're interesting in chatting about this, feel free to email me (in bio) or grab thirty minutes on my calendar: https://calend.ly/labib


That sounds interesting. I'll ping you soon.


That's only true for commercial airlines. Private planes have lower safety records because wealthy clients tell pilots to skip safety checks to save time. And personal general aviators don't have copilot's checking their work.


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

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


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

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

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


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

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


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


My default expectation is not zero deaths in surgery. Shit happens.

My expectation is that there should be exactly zero surgical instruments that get left inside the bodies of patients, when they are sown up, or zero cases of the wrong organ being removed.

And yet, there's >1,000 cases a year of the former, in the US alone.


Have you ever heard of a commercial airline advertising its premium maintenance ?


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

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

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


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


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


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

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


Which is what they are designed to do. Eliminate stupid absent minded mistakes.


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


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

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

- everyone, let's all do this thing!

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

- but you've bastardized the original idea beyond recognition

- doesn't work!

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

edit: formatting


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


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

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


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

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

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

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


Spectacles, testicles, wallet, watch! :)


I didn't even keep a list for that -- it was easier to keep a number. There were three things I needed to remember.


I am somewhat obsessed with improving my driving skills, particularly w.r.t. anticipation and accident avoidance. I also got into the habit of using checklists for important but repetitive tasks after reading Gawande's book,

Now I am kicking myself that I never thoguht about applying point-and-call to driving. I can absolutely see the benefit, but would need to think about the details. Do you point out only traffic signs and signals, or things like potential threats too?


The biggest use for me is turning from a static position, e.g. left from a cross-street, having started this after I made a left turn but was t-boned, mind you I've always been religious about seatbelts, checking turns (left-right-left), etc. When doing a static turn I will point-and-call left, "Clear Left," point-and-call right, "Clear Right," point-and-call left again "Clear Left," then with both hands on the wheel say "Go."

I will look-and-call for lane changes, pretty much as you would imagine look over the shoulder and "Clear Left," then "Turning." Same goes for right. For me it is more action oriented, to make sure I've assessed the area for issues. I haven't done anything like call outs for threats, but now I'm kicking myself for not thinking of that. I already do that religiously in FPS games, I could see how doing that would be good to get and stay in the habit of active scanning, "Pedestrian crossing, two o'clock." Might have to try that one out too, after all my friends will love that development :)


I can't imagine this with a straight face, but I do think you're a safer driver for it. I imagine an accident like that would rapidly change that. Even a small fender bender changes my driving rapidly for a good period of time. Too bad I can't get over myself :)


> I can't imagine this with a straight face

If it works it ain't stupid. That's good enough for me.

> Even a small fender bender changes my driving rapidly for a good period of time.

That's always a good thing. Not sure what helps long-term other than commitment to a wonky habit.

Like a good engineer, I do a post-mortem after any incident or near-incident. Crashes, tickets, brake-slams, etc. Unfortunately a lot of near-incidents are of other drivers that no amount of preparation can prevent, e.g. drivers turning onto your road severely under speed, drivers stopping short (10+ car lengths) near lights to be nice and let someone turn into or across the road.


UPS and some other drivers have variations on this (around scanning).


What's actually on your point and call for driving?


To avoid extra chatter, see this reply: https://news.ycombinator.com/item?id=20629895


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


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

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


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


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


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


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

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


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


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


Well, you actually just need an Alexa there reciting the checklist and waiting from a yes before moving to the next item.

Since it is intended to be in a hospital, that's a $40K Alexa that must be created by somebody with the right connections. But all that you need is an Alexa.


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


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

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


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


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


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

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

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

--- Anecdote ---

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

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

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

--- Anecdote Extended ---

I suffered an unpleasant complication from this during a procedure.

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

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

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

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

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

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

Until I woke up in the middle of the procedure!

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

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

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

I bet that checkbox was ticked though.


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


If I saw both Mark the surgical site and Introduce yourself by name on the list, I would also be suspicious about which items were saving lives and which were wasting my time.

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

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


Consciously marking the surgical site ensures we have the right surgical site. A wrong site surgery 'never event' happens nearly 100 times a year in the US.

The introduce yourself by name item is less crucial, but ensures everyone knows who everyone is, especially in larger hospitals. In a stressful environment, it might be the difference between fumbling and not. Apparently it also increases the likelihood that someone will speak up if there is an issue noticed.


Presumably you consider Mark the surgical site to be saving lives, and Introduce yourself by name a waste of time.

However, there is a reason for the latter item. There have been many plane crashes in which at least one cockpit crew member had some inkling that something was wrong [1], but their warnings were ignored, often when there was a big authority gap. Crew Resource Management [2] was developed to address this.

Introducing yourself by name is designed to emphasise that the group is now a team with a common purpose, and everyone, from the lead surgeon to the nurse, can and should speak up if something looks awry.

Quite some thought and research has gone into this. Obviously, this doesn't mean that the ideas can't be criticised, but a facile dismissal like yours is unwarranted and might be one reason the checklists don't live up to their potential.

[1] Some examples:

The Tenerife disaster, 583 fatalities: 'On hearing this, the KLM flight engineer expressed his concern about the Pan Am not being clear of the runway by asking the pilots in his own cockpit, "Is he not clear, that Pan American?" Veldhuyzen van Zanten emphatically replied "Oh, yes" and continued with the takeoff.' https://en.wikipedia.org/wiki/Tenerife_airport_disaster#Comm...

United Flight 172: 'The captain focused on the landing gear problem for an hour, ignoring repeated hints from the first officer and the flight engineer about their dwindling fuel supply. Only when the engines began flaming out did he realize their dire situation.'

https://en.wikipedia.org/wiki/United_Airlines_Flight_173

Korean Air 801: 'The crew noticed that the aircraft was descending very steeply, and noted several times that the airport "is not in sight." Despite protests from flight engineer Nam that the detected signal was not the glide-slope indicator, Park pressed on.' https://en.wikipedia.org/wiki/Korean_Air_Flight_801#Accident

[2] https://en.wikipedia.org/wiki/Crew_resource_management


I don't dispute your point, put those seem like examples when someone where someone picked up on a problem and said something, and still nothing was done.

Seems doubtful that everyone saying their name would have fixed any of those problems...


One of the core features of crew resource management is that it empowers the crew as a whole with formal methods of communicating with people that rank above or below them in a way that (ideally) sidesteps the ego problem.


Interesting that this article on graded assertiveness begins by using the formal title of the person being queried: https://gcaptain.com/graded-assertiveness-captain-i-have-a-c...


I recently had a very minor surgery scheduled to have something removed, on the right side. The doctor was filling out the surgery form and checked the "left" box.

It was because on the form, the "right" checkbox was on the left side, and the "left" checkbox was on the right.

(He immediately caught it and corrected it.)


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


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

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


Don't laugh. Mistakes happen, especially with body parts that we have two of, and it's heartbreaking when it does.

Amputating the wrong limb, removing the good kidney instead of the bad kidney...




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