The brain is a careless beast. Mostly, I blame my carelessness on the limited capacity of working memory – it can hold seven discrete items, plus or minus two – which means that we’re constantly forcing ideas to exit the stage of awareness. And so thoughts come and go, as we try to juggle the demands of the real world with the feeble processing powers of the mind. For instance, as I was packing for my latest work trip, I went into the bathroom to grab my toothbrush and toothpaste. I grabbed the toothbrush, opened up the drawer to get the toothpaste, but then I noticed all these other things to pack. (Q-tips, deodorant, floss, etc.) The end result is that I forgot my toothpaste.
These cognitive limitations become especially striking when we’re executing complex tasks, like medical surgery. Everything I know about the operating room I learned from Gray’s Anatomy (so feel free to ignore this next sentence) but it does seem like cutting someone open involves an exquisitely intricate sequence of events. The key, then, is to come up with simple tricks that help us compensate for the constraints of cognition. The rest of us have post-it notes and iPhones, but what do surgeons have?
Deaths and complications dropped by an astounding one-third when operating room doctors and nurses completed a simple safety checklist before, during, and after surgery, according to a study led by Harvard researchers.
The eight hospitals that participated in the international study collectively reduced complications during hospital stays from 11 percent of patients before they began using the checklist to 7 percent of patients when using the checklist. Deaths dropped from 1.5 percent of patients to 0.8 percent.
“It was beyond anything we expected,” said Dr. Atul Gawande, senior author of the Harvard School of Public Health paper and a surgeon at Brigham and Women’s Hospital. The impact of all the items on the checklist “put together seems to have produced these really remarkable results,” he said.
Gawande, an advocate of the surgical checklist who began using it in his own operations a year ago, said he hopes that the results will help win over surgeons and other operating room staff who are skeptical about the usefulness of checklists and believe they waste precious minutes when pressure to turn over operating rooms quickly is greater than ever.
While the study was published online by the New England Journal of Medicine yesterday, the Brigham and some other US hospitals had already implemented the 19-step checklist in their operating rooms, based on early word about the strength of the data. The Brigham, which was not part of the study, began using the checklist a month ago in general and cardiac surgery and plans to roll it out to other specialties over the next several months, Gawande said.
The checklist is based on World Health Organization guidelines and takes only a couple of minutes to complete. It requires operating room staff to complete a series of verbal steps before giving the patient anesthesia, before the incision, and before the patient leaves the operating room. These steps include verifying out loud that an anesthesia safety check was completed and that surgeons are about to perform the correct procedure; confirming that all team members have introduced themselves by name to one another and discussed any concerns; and verifying that all sponges and needles are accounted for after surgery, and that none has been left inside the patient.
To be honest, it’s a little terrifying that a simple checklist could have such dramatic consequences. But the point is that surgeons are constantly shifting their attention from one task to the next, which means that the item that just occupied their mental scratchpad (like that sponge, or the administration of anesthesia) is now gone. That’s why a checklist can be so helpful: it forces the doctors to think, if only for a moment, about what they’ve just forgotten.
It’s also worth noting that pilots have been relying on checklists for decades.