Quotes:
Such failures carry an emotional valence that seems to cloud how we think about them. Failures of ignorance we can forgive. If the knowledge of the best thing to do in a given situation does not exist, we are happy to have people simply make their best effort. But if the knowledge exists and is not applied correctly, it is difficult not to be infuriated.What do you mean half of heart attack patients don’t get their treatment on time?
That means we need a different strategy for overcoming failure, one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our inevitable human inadequacies. And there is such a strategy— though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies. It is a checklist.
For every drowned and pulseless child rescued, there are scores more who don’t make it—and not just because their bodies are too far gone. Machines break down; a team can’t get moving fast enough; someone fails to wash his hands and an infection takes hold. Such cases don’t get written up in the Annals of Thoracic Surgery, but they are the norm, though people may not realize it.
One of the most common diagnoses, it turned out, was “Other.”
These checklists accomplished what checklists elsewhere have done, Pronovost observed. They helped with memory recall and clearly set out the minimum necessary steps in a process.
All were amenable, as a result, to what engineers call “forcing functions”: relatively straightforward solutions that force the necessary behavior... You want people to make sure to get the stupid stuff right.
the major advance in the science of construction over the last few decades has been the perfection of tracking and communication
Surgery has, essentially, four big killers wherever it is done in the world: infection, bleeding, unsafe anesthesia, and what can only be called the unexpected.
Each one was remarkably brief, usually just a few lines on a page in big, easy-to-read type. And each applied to a different situation. Taken together, they covered a vast range of flight scenarios.
There are good checklists and bad, Boorman explained. Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat the people using the tools as dumb and try to spell out every single step. They turn people’s brains off rather than turn them on. Good checklists, on the other hand, are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything—a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps—the ones that even the highly skilled professionals using them could miss. Good checklists are, above all, practical.
The checklist cannot be lengthy. A rule of thumb some use is to keep it to between five and nine items... after about sixty to ninety seconds at a given pause point, the checklist often becomes a distraction from other things.
the look of the checklist matters. Ideally, it should fit on one page. It should be free of clutter and unnecessary colors. It should use both uppercase and lowercase text for ease of reading. (He went so far as to recommend using a sans serif type like Helvetica
a checklist has to be tested in the real world
The final WHO safe surgery checklist spelled out nineteen checks in all.
I saw a gallbladder operation in which the surgeon inadvertently contaminated his glove while adjusting the operating lights. He hadn’t noticed. But the nurse had. “You have to change your glove,” the nurse told him in Arabic. (Someone translated for me.) “It’s fine,” the surgeon said. “No, it’s not,” the nurse said. “Don’t be stupid.” Then she made him change his glove.
Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is.
Discipline is hard—harder than trustworthiness and skill and perhaps even than selflessness.
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