Respectful Insolence

ResearchBlogging.orgAbout a year ago, I discussed an article by Dr. Atul Gawande describing a quality improvement initiative that appeared to have been stalled by the Office for Human Research Protections and its apparent tendency to apply human subjects research protection rules to initiatives that are not exactly research using human subjects. The problem appeared to be an excessively legalistic and a “CYA” attitude more than a genuine concern for protecting human subjects. At the time, I was more concerned with the ethical and policy implications of the story rather than the actual research itself. After all, what was being examined was not something new or experimental. It was nothing more than a checklist designed to remind doctors placing central venous catheters to use rigorous sterile technique, and, not surprisingly, its use was associated with a dramatic decrease in catheter infections. Given that the checklist contained nothing more than tried-and-true infection control measures, it was not surprising that catheter infections dropped. What was somewhat surprising is how much they dropped.

One question that arises from these results is: Do these lists have a more general utility? In last week’s issue of the New England Journal of Medicine, a study published by Gawande and numerous collaborators takes the use of checklists to a whole other level.

The study, A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population, represents the fruit of a multinational collaboration that tested a very simple intervention, namely a surgical checklist designed to verify a number of factors, such as patient identity, surgical site, and others. Some elements of this sort of checklist have been in place in most U.S. hospitals, elements such as a “time out” to verify patient identity, operation being performed, and correct surgical site before the patient is placed under anaesthesia, but the list examined in this study goes much further than most such lists in the U.S., or anywhere else, for that matter.

The checklist was tested at eight hospitals scattered throughout the world, both in developed countries and Third World countries. Sites included London, Seattle, Toronto, Tanzania, India, Jordan, the Philippines, and New Zealand. These hospitals had varying safety measures in place before the study, and none of them were as extensive as the checklist introduced as part of the study, as described here:

The intervention involved a two-step checklist-implementation program. After collecting baseline data, each local investigator was given information about areas of identified deficiencies and was then asked to implement the 19-item WHO safe-surgery checklist (Table 1) to improve practices within the institution. The checklist consists of an oral confirmation by surgical teams of the completion of the basic steps for ensuring safe delivery of anesthesia, prophylaxis against infection, effective teamwork, and other essential practices in surgery. It is used at three critical junctures in care: before anesthesia is administered, immediately before incision, and before the patient is taken out of the operating room. The checklist was translated into local language when appropriate and was adjusted to fit into the flow of care at each institution. The local study team introduced the checklist to operating-room staff, using lectures, written materials, or direct guidance. The primary investigators also participated in the training by distributing a recorded video to the study sites, participating in a teleconference with each local study team, and making a visit to each site. The checklist was introduced to the study rooms over a period of 1 week to 1 month. Data collection resumed during the first week of checklist use.

The checklist itself involves some fairly basic things. It’s divided into three sections. The “sign-in” section has typical elements, such as verifying patient identity; making sure that surgical site is properly marked with a marking pen; making everyone aware of any patient allergies; checking the pulse oximeter; and determining if there is a risk of aspiration or significant blood loss. The preop “time out” involves such things as once again verifying the patient identity and surgical site; making sure that any preop antibiotics have been given less than 60 minutes prior to skin incision; confirming that all appropriate imaging results are available, correct, and show what they are reported to have shown; and reviewing anticipated critical events. Finally, the “sign out” phase involves the typical surgical necessity of making sure that the sponge and instrument counts are correct before waking the patient up; checking any specimens to make sure they are labeled correctly; and reviewing aloud concerns about any issues that might interfere with the recovery of the patient.

Pretty simple, isn’t it? Moreover, none of this is anything that is not only common sense (verification of surgical site) or reiteration of science-based surgery (preoperative antibiotics that are given after the skin incision is made are completely useless and if they are given more than 60 minutes prior to surgery they are likely to be less effective). The only difference is that these practices were systematized, and the health care teams were required to verify that they were being done appropriately. Perhaps that’s why the results were so striking and unexpected. No, it wasn’t unexpected that the introduction of this checklist would probably be associated with a decrease in complications and possibly even surgical mortality. That wasn’t a huge surprise. What was a huge surprise was how much this checklist appeared to decrease morbidity and mortality. Mortality decreased by one half (1.5% to 0.8%) and complications by a third (11% to 7%).

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The results were so striking that the principal investigator of the catheter infection study that I mentioned at the beginning of this post was quoted thusly:

The results were so dramatic that Dr. Peter Pronovost, a Johns Hopkins University doctor who proved in a highly influential study a few years ago that checklists could cut infection rates from intravenous tubes, said he was skeptical of the findings.

One possible flaw, he said, is that “you had people who bought into the system collecting their own data.”

I find this explanation for the results to be pretty unlikely, given the description of the methodology in the paper, but I can’t rule it out. I also find it strange that Dr. Pronovost would say such a thing, given that the results from his own study were even more dramatic than this one, with catheter sepsis decreased by two thirds and overall catheter infections decreased from 4% to zero. One aspect of these results is that the results at “low income” sites were more striking when compared with the results at “high income” sites in the developed world, with no significant decrease in the death rate in the wealthiest countries due to this list. This, too, is not that surprising, as most of the wealthiest countries already have systems in place to assure that measures designed to decrease or eliminate wrong site surgery, wound infections, and other complications, at least more so than hospitals in more impoverished nations. However, even in the wealthiest countries, most existing checklists are not as comprehensive.

So was it the introduction of checklists that resulted in this improvement? That’s difficult to say definitively from just this study. Certainly it is possible, but exactly how is harder to ascertain. One possibility is that the introduction of such checklists leads to a systemic improvement in how care is delivered driven by adherence to the principles embodied in the checklist. As the authors speculate in the discussion:

Whereas the evidence of improvement in surgical outcomes is substantial and robust, the exact mechanism of improvement is less clear and most likely multifactorial. Use of the checklist involved both changes in systems and changes in the behavior of individual surgical teams. To implement the checklist, all sites had to introduce a formal pause in care during surgery for preoperative team introductions and briefings and postoperative debriefings, team practices that have previously been shown to be associated with improved safety processes and attitudes and with a rate of complications and death reduced by as much as 80%. The philosophy of ensuring the correct identity of the patient and site through preoperative site marking, oral confirmation in the operating room, and other measures proved to be new to most of the study hospitals.

This study also had some significant drawbacks. For example, it was a “before and after” study with the same staff, which introduces some potential for bias in that there was no randomization. The authors themselves concede:

This study has several limitations. The design, involving a comparison of preintervention data with postintervention data and the consecutive recruitment of the two groups of patients from the same operating rooms at the same hospitals, was chosen because it was not possible to randomly assign the use of the checklist to specific operating rooms without significant cross-contamination. One danger of this design is confounding by secular trends. We therefore confined the duration of the study to less than 1 year, since a change in outcomes of the observed magnitude is unlikely to occur in such a short period as a result of secular trends alone. In addition, an evaluation of the American College of Surgeons’ National Surgical Quality Improvement Program cohort in the United States during 2007 did not reveal a substantial change in the rate of death and complications (Ashley S. personal communication, http://acsnsqip.org). We also found no change in our study groups with regard to the rates of urgent cases, outpatient surgery, or use of general anesthetic, and we found that changes in the case mix had no effect on the significance of the outcomes. Other temporal effects, such as seasonal variation and the timing of surgical training periods, were mitigated, since the study sites are geographically mixed and have different cycles of surgical training. Therefore, it is unlikely that a temporal trend was responsible for the difference we observed between the two groups in this study.

They also concede that there may be a bit of the “Hawthorne effect” contributing to the improvement, namely the phenomenon that people tend to perform differently, usually better, when they know they are being watched. On the other hand, who cares if the results are due to the Hawthorne effect if there was a real improvement? In that case, keep watching, I say.

One interesting aspect of this initiative (interesting to me, at least) is the level of hostility to the results of the catheter study and this study that I have encountered. Doctors tend to resist checklists. I don’t know if this is anything unique to physicians, but given that airline pilots have used preflight checklists for years I’ve always had a hard time understanding the visceral reaction that such lists seem to provoke in physicians. It’s as though too many of us consider ourselves so superior to our fellow human beings that the utility of such lists do not apply to us, we never forget to do anything, and never need reminding to do what we should be doing in the first place. To some extent, I can understand in that I used to make fun of what I used to disparage as the “mindless ritual” of my having to mark which breast I was going to operate on and to do a “time out” to verify it with the entire surgical staff in my operating room. I even used to say that once something is made into a rigid policy or checklist, it’s an excuse to stop thinking and mindlessly go through the motions. To some extent, I still think it’s important to guard against that tendency, but I’m far more supportive of checklists than I used to be, to the point that it disappoints me to see a fellow surgeon (from the town where I did my surgery residency, yet!) dismiss these results so blithely:

Certainly, there is something to be said for meticulous routines when it comes to surgery or other procedures. But do we need mandatory 19 item checklists? Why stop there? Why not make it a 40 item checklist? Why not make the attending surgeon write an essay on how to avoid complications before every case? Or how about having the surgeon and all assistants read the chapter corresponding to the proposed operation from the textbook out loud together (alternating paragraphs) prior to making the incision?

It’s good to be organized and precise in surgery. Limited checklists are useful in this regard. We ought to mark our initials on the correct side of the hernia repair. Point taken. Nothing groundbreaking here. We don’t want to be operating on the wrong leg or leaving sponges inside bellies. But it’s rather a ridiculous leap to think that death rates can be halved just by following a series of irritating instructions on a laminated list.

I was disturbed to see in this reaction the arrogance that I used to have when it came to these lists, with a huge dash of the logical fallacy known as the slippery slope argument taken to the extreme of ridicule. Certainly, such lists can be irritating. Certainly, I myself have been irritated by them on occasion, even to the point of making fun of them. Certainly, these lists can be made too long and onerous. However, as harsh as this may sound, the objection above is simply nothing more than the logical fallacy of argument from incredulity, the same argument frequently used by creationists to dismiss evolution because they cannot conceive how evolution might have formed an eye. To dismiss these results simply because one can’t imagine how they might be true or valid does not demonstrate that they are not true or valid; it only demonstrates a lack of imagination and a bit of stubbornness. If this study were the first one that showed that surgical checklists and various means of verifying operative site can significantly reduce complications and wrong site surgery mistakes, then that would be one thing. But it’s not. There’s lots of other evidence in the medical and surgical literature (and cited by Gawande’s paper) that various checklists do contribute to decreased complication rates in various settings. It is not all that surprising that such a checklist would do so for surgery.

The problem, I think, is that surgeons like Buckeye Surgeon have a distressing tendency to view such studies as assaults on them as surgeons, as accusations that they are not good surgeons if they do not follow such lists, the implication being that they are being told they need reminders to do what they know they should do. That is the wrong attitude to take. No one is accusing surgeons like Buckeye of being negligent or insufficiently conscientious. However, there is a significant body of literature that indicates that doctors do not do what they think they do a significant proportion of the time. For example, in studies of hand-washing, physicians often self-report that they always or almost always wash their hands between patients. Objective observations by investigators often show otherwise. Human psychology fills in the gaps. There is no reason to think that the same thing is not also true of surgeons. Indeed, even at the Seattle site, prior to the introduction of the checklist some of the basics on the list were performed considerably less frequently than one would think they should be in such an advanced hospital. In addition, there is a culture inculcated in surgeons that we are always the captains of the ship. Consequently, the collaborative nature of such checklist systems, which require surgeons to submit themselves to nurses and other nonphysicians who verify compliance with the list, often grates, particularly when combined with surgeons’ general dislike of bureaucracy:

Surgical safety is always paramount when I do an operation. But to use the results of this study as definitive proof that by simply implementing Dr Gawande’s 19 point checklist will save thousands of lives is misguided. This was a non-randomized, non-blinded study. It’s not hard science. Long, indepth checklists are only going to complicate health care. Will we need different checklists depending on the operation? Will there be separate checklists for doctors vs nurses vs anesthesia staff? Who will be in charge of determining each checklist? A subcommittee of the AMA? A national bureaucracy>

Common sense and moderation, as usual, ought to be our guiding principles. The article is useful in the sense that it highlights the potential benefits of a checklist; but let’s not fall over ourselves thinking that we’ve found some sort of panacea….

These are not arguments based on a sound understanding of science. Indeed, the remark that, because this study was not randomized or blinded, it is not “hard” science is really off the mark and epitomizes what irritates me the most about how many doctors have come to view evidence-based medicine. That view seems to be that, if it is not a randomized double blind study, it is meaningless or bad science. That is far too narrow a view of evidence-based medicine. After all, some interventions, for example many surgical interventions, often can’t be studied using blinded studies, and systems studies often can’t be blinded or randomized. That doesn’t mean such issues can’t be studied rigorously; it simply means that different methods are needed to study them and that it’s more difficult to control for confounding features.

Checklists are not a panacea. Indeed, they even have the potential to do harm if they are too long, too onerous, or filled with items that have nothing to do with patient safety and reducing complications. However, the slippery slope argument against them is unconvincing. There is no inevitability to their growing to the ridiculous proportions used to mock them. Indeed, research is what will allow investigators to figure out what items do and don’t belong on such lists. Nor is the argument that we don’t know exactly how these lists contribute to improved outcomes, in essence an argument from ignorance, particularly compelling either. It’s quite possible that such lists, when properly designed and using science-based principles, contribute to systematizing best practices that hospitals and surgeons should be doing anyway. If so, why should that be an argument against them? Finally, the argument from consequences opponents of these lists use, namely that they will somehow erode the magic professionalism of surgeons and reduce them to just technicians following a list, remains unconvincing as well. Are airline pilots considered any less “professional” than surgeons? They use checklists all the time. What about clinical care pathway protocols, many of which are more detailed than this surgical checklist? Such protocols have been in place at most hospitals for many years.

There may well be rational, science-based reasons to oppose the creeping influx of checklists and protocols. It may also be that there are right ways and wrong ways to introduce such checklists and that wrong ways could even do harm. However, none of these are reasons not to introduce into more hospitals lists that have been validated in studies as being useful and let the data show whether these lists work when used more widely. Unfortunately, a lot of the resistance I sense from my colleagues seems to derive more from an emotional reaction to what they perceive as being told what to do or as an erosion of their autonomy than from science, risk/benefit ratios, or economic concerns about the expense of introducing such lists.

REFERENCE:

A. B. Haynes, T. G. Weiser, W. R. Berry, S. R. Lipsitz, A.-H. S. Breizat, E. P. Dellinger, T. Herbosa, S. Joseph, P. L. Kibatala, M. C. M. Lapitan, A. F. Merry, K. Moorthy, R. K. Reznick, B. Taylor, A. A. Gawande (2009). A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population New England Journal of Medicine DOI: 10.1056/NEJMsa0810119

Comments

  1. #1 Mu
    January 20, 2009

    The effect of checklists is astonishing. We had a consistent quality problem in chemical production, despite detailed runners describing (and requiring verification) of each step for each batch. Only after we switched from “write down your measurements” to “have your measurements written down by the second person” did our quality suddenly improve drastically (from 1 in 10 to 1 in 50 bad batches). An investigation found the most likely culprit being swapped bottles, if someone rearranged the order of bottles, weights were routinely correct – for the ingredient in the left, middle and right bottle, not for ingredient one, two and three as required by the runner.

  2. #2 dusonfnp
    January 20, 2009

    Very interesting. Generally, checklists (or any other system) work as long as it’s easier to use them correctly than to do otherwise. The hospital where I work is constantly trying to improve its systems, but the powers that be haven’t figured out that part of effective change is making it easier to do it right than to do it wrong.

    I’ve also read that there has been resistance to use of algorithms in medicine, although it’s been shown that algorithms work. So many doctors and nurses want to play up the “art” of healing rather than the “craft.” Maybe it’s because we are afraid that checklists and algorithms (and computerized prescription ordering systems) might cause us to be perceived as doing something that any trained monkey could do. Hmmmm, NASA parallel with astronauts and monkeys, totally unintended when I started writing, but there it is.

  3. #3 D. C. Sessions
    January 20, 2009

    A common topic of debate is whether surgeons are cockier than fighter jocks or vice versa. However, the fighter jocks are well known to be absolute sticklers for checklists and one of their proverbs is that “there are old pilots and there are bold pilots, but there are no old, bold pilots.”

    It’s worth inquiring into the cultural roots of the difference.

    I can suggest a few points:

    1) Fighter jocks are competing against other fighter jocks — and someone always comes out second best. They live with challenges to their abilities, so the “are you questioning my ____” issue is simply not on the table.
    2) Fighter jocks are on close terms with their mechanics and other engineering types. We, in turn, live with Murphy and have long since incorporated checklists etc. as part of our culture because we know that shit happens. Maybe it rubs off.
    3) When a surgeon screws up, someone else dies. When a fighter jock screws up, the fighter jock dies. It really doesn’t matter if the engine flamed out or whether the pilot committed CFIT — either way, dead pilot.

    Fighter jock culture makes no excuses for pilots. It doesn’t matter whether his plane ingested an entire flock of geese, lost hydraulic power, had the wings come off, and collided with blue ice falling from a passing jetliner. At the same time. A Real Pilot ™ would have pulled it out somehow; failure to do so simply proves that the loser wasn’t a Real Pilot [1]. No excuses.

    Try reading The Right Stuff and imagine the surgical equivalent.

    [1] Yes, this is a defensive myth. It protects the survivors from facing the fact that it could happen to them.

  4. #4 Karl Withakay
    January 20, 2009

    This was such a well written post, you preempted most of my comments.

    While I read your posts on your “targets of respectful insolence”, I write down the logical fallacies I find on a post-it, to see if you note any I didn’t catch, or if I caught any you didn’t note. I also note anything else I might want to comment on, but this time you covered everything I had on my post-it, the lack of randomization, the Hawthorne effect, the slippery slope argument, etc.

    About the only thing I can think to add would be my curiosity as to whether longer term use of the checklist (say 5 years), especially outside of a formal observational study, might result in a slight reversion to the mean of the results. I guess one key to the checklist process is that the participants are all observing each other and ensuring the checklist is consciously followed.

    In the world of IT, I have determined that just having a checklist isn’t enough; you need to have a good, structured system like pilots or those in the study presumably have. When an individual works off a checklist by themselves, there is a tendency to do three or four things, and then check off four or five things, not realizing that you skipped something you just checked off.

  5. #5 anon
    January 20, 2009

    I’m completely in agreement with DC.

    Surgery could learn enormously from aviation. Error rates in aviation are simply not tolerated, surgical egos in aviation are simply not tolerated. Safety is the number one preoccupation.

    Safety initiatives in surgery backed by randomised controlled trials (fatigue and work hours for instance) are dismissed by senior surgeons as not relevant to them. Pilots on the other hand…

  6. #6 Orac
    January 20, 2009

    Safety initiatives in surgery backed by randomised controlled trials (fatigue and work hours for instance) are dismissed by senior surgeons as not relevant to them

    What randomized controlled trials? I’m not aware of any randomized controlled trials that show, for example, that resident work hour restrictions have resulted in improved patient care outcomes, but it’s quite possible that I have missed them. All I’ve seen is retrospective before-and-after data, less impressive than the current study under discussion, and these have in generally shown no difference in patient outcomes or possibly a very iffy improvement.

    Before anyone attacks me for being an old fuddy-duddy denialist who can’t accept that work hour restrictions are probably a good thing, see:

    http://scienceblogs.com/insolence/2008/12/limiting_physician_trainees_work_hours_a.php

    Basically, what I’m saying is that the evidence that work hour restrictions lead to better patient outcomes is, at least to my reading thus far, considerably weaker than the evidence that checklists do.

  7. #7 Alex Besogonov
    January 20, 2009

    Checklists are teh win!

    I’m not a surgeon, not even a medical professional. I’m a programmer. However, when I first heard about checklist study (several months ago here on Scienceblogs) I decided to try them at my job.

    Results were striking! Time for handling a problem ticket almost halved after I had introduced checklists for our support staff.

  8. #8 Orac
    January 20, 2009

    About the only thing I can think to add would be my curiosity as to whether longer term use of the checklist (say 5 years), especially outside of a formal observational study, might result in a slight reversion to the mean of the results. I guess one key to the checklist process is that the participants are all observing each other and ensuring the checklist is consciously followed.

    That is, of course, an excellent question. My expectation/hypothesis would be that with time the checklist might be less rigorously followed and things might revert back to the mean. However, I’d also guess that they wouldn’t revert all the way back to the mean; i.e., some improvement would remain. Only further study can determine whether that would happen.

  9. #9 JustaTech
    January 20, 2009

    I am very excited to see this paper discussed here. Many years ago I shared an office with Dr. Gawande (as a high school student intern) and helped him with an article on surgical materials left in patients.

    Rather, I sorted through approximately 1000 “adverse incidents” reports looking for left over surgical implements at a hospital in Colorado. Didn’t find any, but I did learn all about delusional patients ripping out IV’s and bladders that got ‘nicked’ during c-sections. I was actually impressed I didn’t find any cases of “where’s that retractor?” I’m sure Dr. Gawande doesn’t remember me, but I like to think I helped a bit.

  10. #10 SimonG
    January 20, 2009

    Like a couple of other posters, I work in IT and I’ve found checklists, (or similar) to be extremely effective at cutting out dumb errors.

    It’s still possible for complacency to creep in over time. At one point I used to prepare a new checklist for each specific instance of a task. (Well: custom-tailored rather than actually new.) That was really effective but became a bit tedious eventually, and time consuming. So I stopped taking quite so many pains and I think my work did suffer. As you suggest probably not all the way back to where things were before I used check lists, although when I use(d) checklists effectively my work can be rather good so there was quite a lot of scope for deterioration.

    I found a good checklist to be particularly useful when things go wrong. It can help one to be sure that all of the correct things have been done and help to identify the cause of the problem.

    Surgery isn’t quite the same I’m sure. If nothing else, human patients are a lot more complex and unpredictable than computer systems. But I suspect that any complicated human activity could benefit from a degree of standardisation and control.

  11. #11 AnthonyK
    January 20, 2009

    I love Atul Gawanda’s work (and Complications is even better than Better), but some of his best stuff is in The New Yorker. This article from last year describes in his beautiful style the importance of checklists:
    http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?currentPage=1
    (Oh Orac, you’re good but…)
    One of the many interesting points is that often the enforcement of these simple procedures is in the hands of nurses, and some surgeons out there just resent this. It makes one think: “Research proposal: What is the correlation between surgical arrogance and post-operative recovery rates?”
    Present company excepted, of course.

  12. #12 khan
    January 20, 2009

    It’s as though too many of us consider ourselves so superior to our fellow human beings that the utility of such lists do not apply to us, we never forget to do anything, and never need reminding to do what we should be doing in the first place.

    I have realized this in my own life: right it down, schedule it, check it off…

    I am glad to see that you can stomp down part of your (self admitted) ego and realize that facts can run against intuition.

    (I am not trying to be insulting.)

  13. #13 anon
    January 20, 2009

    “Basically, what I’m saying is that the evidence that work hour restrictions lead to better patient outcomes is, at least to my reading thus far, considerably weaker than the evidence that checklists do.”

    I absolutely agree with that. Checklists are cheaper too.

    On the training of surgeons – I get that practice of a physical skill requires a great deal of practice and experience in the OR. But the practice of training surgeons may itself cause retardation of that learning. Time in the OR is without any doubt very important. But the gains from each additional hour of work are not necessarily positive (i.e. it is more than possible that working less hours may improve learning). Is 80 hours a week really not enough? The problem facing surgery now is that self-regulation may not be allowed by society at large. General lay-people are aghast at the propsoed

    The historical reasons for the surgical residency program date back to WS Halsted http://linkinghub.elsevier.com/retrieve/pii/S1470204507700761 (behind a paywall I’m sorry to say.)
    When you look at what he had to do (i.e. the cocaine addiction) to keep up with his own system you have to wonder what the motivations of senior surgeons these days to retard change of this system are guided by? (And I’m not implying drug addiction in present day surgeons). Is it simply a feeling that because you were punished through training that the juniors of today must suffer a similar fate? The assumption that the status quo is optimal makes no sense to anybody else.

    Is there the fostering of a culture of safety and looking carefully at the way we do things and seeing if there might be a better way?

    Actually you don’t have to look outside of the OR if you want a profession that are seriously into safety. Anaesthesiologists also borrow heavily from aviation human factors ideas.

  14. #14 Chris Ryan
    January 20, 2009

    A very interesting post.

    I am an anaesthetist by training (that’s an anaesthesiologist to your American readers), myself and my colleagues, our learned college and indeed our professional society obviously have a vested interest in the provision of safe anaesthesia care. We are told repeatedly that we must adopt a culture of safety like the aviation industry – check lists are simply one more adoption.

    Anaesthesia probably lends itself more readily to the application of check lists. I have my own lists (which I must admit vary somewhat depending on the type of surgery and anaesthetic) that I run through at various stages during a case ( induction, maintenance and emergence). I find that it is a useful thing to do especially towards the end of a long day when I am feeling a little weary and am worried that through a lapse of concentration I might miss something.

    Some of my colleagues have had at laugh at my expense – thinking I am a little too anal rententive, I now feel vindicated!!!

  15. #15 Militant Agnostic
    January 21, 2009

    I have heard the process the FAA uses for incident reporting has been recommended for reporting medical errors or narrowly avoided medical errors. As I understand it a pilot can report an incident without fear of repercussions. I think there many apects of the avaition industry’s approach to safety besides checklists that would be benificial to other fields such as surgery.

  16. #16 gillt
    January 22, 2009

    I’m scheduled for a hernia surgery in Feb, and as a patient I’d like to be let in on these newfangled checklists: signing off on them pre and post-op. Of course the surgeon could simply lie about pre-marking the site of incision.

  17. #17 Imhotep
    January 23, 2009

    Surgical check lists are fantastic. Resistance to them is mind boggeling, and I find the detractors quiet humorous.

    I am the Chief of Surgery at a large urban hospital and I have met significant resistance to check lists. Another “simple” measure that has created an up roar is ‘changing scrubs’. I am discusted by people that wear scrubs from outside the hospital into the OR and from the OR to their home. Absolute filth.

    Infection control measures are as simple as being clean!

    Great post Orac.

  18. #18 Dan
    February 1, 2009

    Thoughts about Obesity

    Obesity is when excess body fat accumulates in one to where this overgrowth makes the person unhealthy to varying degrees. Obesity is different than being overweight, as it is of a more serious concern. As measured by one’s body mass index (BMI), one’s BMI of 25 to 30 kg/m is considered overweight. If their BMI is 30 to 35 kg/m, they are class I obese, 35 to 40 BMI would be class II obese, and any BMI above 40 is class III obesity. Presently, with obesity affecting children progressively more, the issue of obesity has become a serious public health concern.
    Approximately half of all children under the age of 12 are either obese are overweight. About twenty percent of children ages 2 to 5 years old are either obese are overweight. Worldwide, nearly one and a half billion people are either obese or overweight. In the United States, about one third of adults are either obese or overweight. It is now predicted that, for the first time in about 150 years, our life expectancy is suppose to decline.
    Morbid obesity is defined as one who has a body mass index of 30 kg/m or greater, and this surgery, along with the three other types of surgery for morbid obesity, should be considered a last resort after all other methods to reduce the patient’s weight have chronically failed. Morbid obesity greatly affects the health of the patient in a very negative way. It has about 10 co-morbidities that can develop if the situation is not corrected. Some if not most of these co-morbidities are life-threatening.
    One solution beneficial in many cases of morbid obesity if one’s obesity is not eventually controlled or corrected is what is known as gastric bypass surgery. This is a type of bariatric surgery that essentially reduces the volume of the human stomach in order to correct and treat morbid obesity by surgical re-construction of the stomach and small intestine. Patients for such surgeries are those with a BMI of greater than 40, or a BMI greater than 35 if the patient has comorbidities aside from obesity. This surgery should be considered for the severely obese when other treatment options have failed.
    There are three surgical variations of gastric bypass surgery, and one is chosen by the surgeon based on their experience and success from the variation they will utilize. Generally, these surgeries are either gastric restrictive operations or malabsorptive operations. Over 200,000 gastric bypass surgeries are performed each year, and this surgery being performed continues to progress as a suitable option for the morbidly obese. There is evidence that this surgery is particularly beneficial for those obese patients that have non-insulin dependent Diabetes Mellitus as well.
    So the surgery to correct morbid obesity greatly limits or prevents such co-morbidities associated with those who are obese. Two percent of those who undergo this surgery die as a result from about a half a dozen complications that could occur. However, the surgery reduces the overall mortality of the patient by 40 percent or so, yet this percentage is debatable due to conflicting clinical studies.
    Age of the patient should be taken into consideration, as to whether or not the risks of this surgery outweigh any potential benefits for the patient who may have existing co-morbidities that have already caused physiological damage to the patient. Also what should be determined by the surgeon is the amount of safety, effectiveness, and rationale for a particular patient regarding those patients who are elderly, for example.
    Many feel bariatric surgery such as this should be considered as a last resort when exercise and diet have failed for a great length of time.
    If a person or a doctor is considering this type of surgery, there is a website dedicated to bariatric surgery, which is: http://www.asmbs.org,

    Dan Abshear

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