The Frontal Cortex

Surgery Checklists

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?

This is why I find this recent study, published in the NEJM, so compelling. Here’s the Globe:

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.


  1. #1 Glenn
    January 19, 2009

    When I was Navy nuke on a submarine, we had to do EVERYTHING by the book (aka checklist) no matter how mundane or routine the task. The reason surgeons may be chafing at using a “simple checklist” is simple: ego. Yes, turnaround in a hospital is important, but it pales in comparison to surgeon’s “smarter than thou” culture which breeds doctors who know and do everything with their memory and memory alone. While US medicine has a not-too-stellar record for accidents and gaffes, the US Navy (surprisingly) has never had an accident worth noting (sometimes, with 18 year old recent high school grads!). These “checklists” should have been embraced DECADES ago.

  2. #2 Johan Strandell
    January 19, 2009

    The New Yorker also wrote an article about checklists in medicine a while back. It’s by Dr. Gawande, who’s mentioned in the Globe article.

  3. #3 Schmutzli
    January 19, 2009

    I notice that before I cook, if I write out the recipe and attendant ingredients in the order they are needed, I get much better results. Not obvious what goes wrong otherwise, but the food has that x-factor that is lacking if I don’t organize myself step-wise. So I have adopted the habit.

    Obviously lives are more important, but I intuitively understand how this could be true…

  4. #4 Elizabeth
    January 19, 2009

    After working as an ER MD for a few years, I began to say to myself and others, “I cannot get any better at this {job}” for I had come to realize that I would always have to go through mental check lists and do A, B, C, D, etc. in the routine care of patients. Indeed, it is somewhat contrary to what we learn all our lives, ie, get ‘better’ at what we do. But you can’t.

  5. #5 Texas Reader
    January 19, 2009

    I never forget anything when I travel – I keep (all the time) a toothbrush, toothpaste, anti-perspirant, razor and shaving gel, comb, qtips, etc. etc. in a 1 gallon ziploc “freezer” bag (these are stronger/thicker than the “storage” bags.) Just toss the thing into my checked bag.

    All I ever have to pack is clothing, electronics, jewelry and prescription meds.

    If I’m doing a short trip and not checking my bags, I take along the TSA accepted 1 quart ziploc bag with the really small toothpaste tube and shaving gel in it and take out the bigger liquid/paste items from the 1 gallon ziploc so I don’t get those taken away.

    My memory is really really poor and if I didn’t have travel kits that stay packed I’d be forever leaving home without everything I need.

  6. #6 Jenny Devaud
    January 19, 2009

    NPR recently had a segment on why Scrabble works best with 7 letters and not 8. Exactly what you point out. We can hold 7 things in our brain at once. By the way, I love your blog.

  7. #7 yogi-one
    January 20, 2009

    The checklist is an amazing device. It should not be underestimated. Yes I travel with a checklist. Yes, surgeons and soldiers should have them always.

    Let’s not even talk about how much astronauts have to run through checklists of procedures to insure something small (but critical) is not overlooked. Airline pilots? Check.

    I also use it for my life goals and progress. A checklist of really big life goals. A checklist of goals for the year, for the month, or the week, for the day. Periodic checking my progress against those checklists or updating and changing the checklists if necessary.

    How do you know if what you do today is keeping you moving towards what you want to accomplish this year, or in five years.

    If you haven’t got well-thought-out checklists of these things, I’d venture that you spend a lot of time doing stuff that doesn’t fulfill your sense of meaning in life.

  8. #8 llewelly
    January 20, 2009

    To be honest, it’s a little terrifying that a simple checklist could have such dramatic consequences.

    I’m terrified to learn surgeons do not already use a checklist!

  9. #9 Christian
    January 20, 2009

    I hope you write more on working memory and the new demands the electronic information and inferfaces place on it (e.g. multitasking). I’m a med student, about to graduate and work in the ED, and I am horrified that I will forget an item that will result not in just forgetting a toothbrush, but in something more serious.

    Checklists may seem mundane and tedious, but for me (I try to develop my own) they are insurance and peace of mind that I can go on with my complex multi-tasking and feel reasonably assured that I didn’t forget something. I feel they actually make me more efficient since I don’t need to devote as many valuable executive-function neurons to “remembering what to remember” and so forth.

  10. #10 Fred Z
    January 21, 2009

    I’m with llewelly. I’m not only terrified that doctors have not been using checklists I am outraged.

    Then we get some poor medical student who openly admits he has to create his own checklists. What the effin effin effety eff are the medical schools doing besides sweet eff all?

    Nice work Docs, we always suspected you were selfish, jerk, marginally competent egomaniacs and you just gave us more evidence.

  11. #11 Glen Hoshizaki
    January 21, 2009

    I think the authors might have made a mistake in focusing so much on the checklist itself. I don’t think this study has as much to do with individual cognitive function as the above suggests. This was not just the simple introduction of a checklist for personal use by the surgeon, but instead involved a change in systems and process involving many people. I suspect that whatever improvement in patient outcome there was (and the authors’ do discuss potential confounding factors) was due in large part to the effect these changes caused in improving communication among the various caregiver groups (anesthesiologists, surgeons, OR nurses) as well as giving caregivers a greater understanding of how all the processes fit together to result in patient care.

  12. #12 Maya
    January 21, 2009

    i’d read about the 7 thing way back when, in high school psychology, and was so enraged when we had to start using area codes when dialing local numbers in the boston area – that’s three too many digits guys!

    also, my roommate and i realized something over the course of the election, during countless nights at home, either watching the debates with rapt (and shamelessly irreverent) attention, or just having the coverage on in the background. part of why we loved Obama and Biden was how friggin smart they sounded, all the time. even if they were skirting issues, just like McCain or Palin, they just didn’t sound like they were. and then we realized, Biden ALWAYS lists things out. seriously, every response started off, “well, Tom, first of all,…” and when he was done with the first point, guess what? he could move on to the second. it’s a pretty nifty little trick, if you know you’re able to move on to point 2, you must have made a first point. the pressure to speak clearly and come out on top in those debates must have been enormous, more than i could ever imagine. but somehow Biden never seemed to lose his place like Palin (not to say that checking off the points he wanted to make was the ONLY reason Biden tended to come out on top…)

    i love making checklists. and i’ve started to do it more in work meetings/conversations more too, after watching the debates.

  13. #13 Glen hoshizaki
    January 21, 2009

    Shortly after I wrote my comment above I read Jonah Lehrer’s article, The Next Decider ( Although it might not seem immediately obvious, that article — particularly near the end where Lehrer talks about the value to decision-makers of advisers who have “a diversity of viewpoints” — is more relevant to the NEJM study results than the focus on a checklist as memory aid.

    I do need to point out, however, that a successful surgical procedure is in some ways more like a balance of powers among the three branches of government rather than the result of presidential decision-making. Although the surgeon is still commonly viewed by laypersons as the “captain of the ship”, it’s not quite like that.

  14. #14 Caitlin G.
    January 21, 2009

    By maintaining or reiterating these “lists” internally, we are making such information more permanent in our working memories. Depending on the frequency of such reiteration, the working memory and, thus, the ability to carry out the specific task(s) varies respectively. Surgeons are trained, supposedly, to already have highly-functioning working memories. Therefore, checklists should add little more to the surgeons’ performance.

    The results of the study are likely due to humans’ proven natural tendency to perform a task better if assured or re-assured (as is the case with these checklists) in their ability to do so. If a female student is about to take the SAT and is told that females statistically perform much better on the verbal portion of the tests than males, the student will get a high score in the verbal sections. For the surgeons, the checklists essentially reconfirm that they are extremely capable individuals who are ‘supposed’ to perform a surgery without careless mishaps (e.g. leaving surgical instruments inside a patient). As a result, surgeons will naturally perform better with checklists. Humans are, simply, a self-centered species.

    I’m not at all surprised that checklists weren’t in use already by surgeons…technically, they shouldn’t even need checklists if they are to perform complex, life-endangering surgeries. ALL surgeons run through internal checklists, whether they know it or not. But if written safety guidelines end up saving lives, I’m all for them.

  15. #15 Anibal
    January 23, 2009

    I read elsewhere that NASA measured how many decision pilots take per hour, they are 80 optimal decisions per hour.

    Physicians are not lef behind in the number of decisions made.

    Linking with the post about the issue of “extended mind”, extracortical technology and devices (e.g. checklists, ipod, calculators, pencil and paper…) help with the limitations of our brains in terms of working memory and attention.

  16. #16 Elizabeth
    January 23, 2009

    Reference the comments about doctors / medicine:

    I believe the CHECKLISTS were always there, at least MENTAL ones. No doubt, they have been formalized… yet even with this public formalization of routine protocols, there are co-workers who want to bypass them. It is still the case that when a nurse refuses to accept a syringe of clear fluid that is not labelled (could be saline, contrast material, any of multiple medications), she is ‘bad-mouthed’ rather than the one violating the protocols and checklists.

    It remains a problem that we cannot ‘get better’ at what we are doing; we can merely continue to do the same thing over and over and over again … and that might be contrary to some sense of progress as a human being.

  17. #17 Nathan Myers
    January 24, 2009

    Pilots resisted the introduction of official checklists, too. The statistics on accidents made it obvious, though, that resistance was unreasonable, and all professional pilots follow checklists religiously today. This has been known for decades.

    I’m not just terrified by surgeons failing to use checklists, I’m angry. How dare they play ego games with my loved ones’ lives!

    Of course checklists are just one step. Standard “kits” have long been used in some hospitals, making it impossible for a procedure to start with some essential tool unavailable. In some hospitals, but very few, teams whose members know each others’ habits well routinely work together. In some hospitals, but very few, the teams review each operation immediately after it’s done and identify ways to prevent problems that occurred.

    I’m furious that all hospitals are not all doing all of these things. Medieval arrogance and guild mentality remain with us no more strongly than in medicine.

  18. #18 MargaretWV
    January 26, 2009

    Operating room checklists are a good thing — I thought this study must be a joke. You mean they haven’t been standard for decades?!

    Another reaction, from surgeon Sid Schwab:

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