In The Checklist Manifesto (Amazon, Borders, b&n), Dr. Atul Gawande expands on his previous writing about the work of Dr. Peter Pronovost. Pronovost developed a system to help reduce complications of hospital care, such as infected venous catheters. This system has been very successful. It is based on the idea that some tasks are simply too complex to be error-free. Medical care has become very successful, but also very complex, to the point where one person cannot possibly remember every step in some processes, even simple steps such as scrubbing in.
The simple and successful solution is to create checklists analogous to what pilots use. Even though each step in preparing to fly a plane or place a central line may be simple and easy to remember, there are so many of these steps that it’s easy to drop one.
I’m fortunate to live in a state and work in a hospital that is using this “Keystone” system. Hopefully these checklists strategies will be validated for wider use.
This idea has been gnawing at me since reading a disturbing article in today’s New York Times. The article describes what can go wrong with radiation therapy. There are some terribly intelligent folks working in the field of radiation oncology, a field that requires the collaboration of several kinds of experts including specially trained physicians and physicists. But, like other complex tasks, planning and executing a radiation treatment requires several steps, each of which is vital.
The errors described in the Times article caused horrific injuries. Often they were due to simple errors, such as failing to re-check a setting on a machine. This seems like just the sort of error that would be amenable to a checklist system. It’s a complex task requiring multiple interdependent steps whose potential outcomes are very, very important. Maybe it’s time for the radiation folks to give Dr. Pronovost a call.
(I received an unsolicited free copy of Checklist Manifesto from the publisher.)