liveonearth (liveonearth) wrote,

Books: The Checklist Manifesto by Atul Gawande

Read this book today. Gawande is a surgeon, and so he approaches the question of *how do we avoid making the commonest mistakes* from a medical perspective. His book includes his explorations into the cultures of high-tech construction, investment, and aviation. He finds that when the task at hand is highly complex, there is no one person who can contain and orchestrate it all. So he digs into what we can do to make sure that nothing essential is left out. Almost half of all surgeries are marked by some common error which may have devastating consequences--or it may not.

Before I even finished reading the book, I had begun working on my own set of checklists. How will I remember all the things I must do in each of a billion different medical situations? My memory is fragile enough, I am easily distracted enough, that it is a serious concern. Thankfully, I am a list person, and my filing system is one great reminder note to myself not to forget anything that is highly important. I'm sure I still will, but I am at least realistic about my own humanity: no way can I remember everything I've been taught. But will I be able to find the info in a timeframe that makes the difference to the patient?

There are two major types of checklists, the DO-CONFIRM and the READ-DO formats. The surgical checklist discussed (used by the WHO since 2009) is a DO-CONFIRM format with three "pause points". The DO-CONFIRM format allows a team of participants (nurses, anesthesiologists, etc) to do their jobs, then come together and confirm that every essential item has been covered. One of the essential items is the introductions of all the team members and their roles, because it allows the formation of a new team in which all members feel that they have both responsibility, and a voice. Without this step, some individuals might not speak up when they see an error being made. The team is sharper than any individual could possibly be.

A pause point is the time at which you stop everything and check the list: has it all been done? The first pause point is before anesthesia. Is this the right patient? The right procedure? Do we have permission? Basic stuff. The second pause point is before the incision. Has the patient had the antibiotic within the last hour? Is everything sterile? Is there enough spare blood? Again, basic stuff. The final pause point is before releasing that patient from the operating room.

A DO-CONFIRM checklist is more like a recipe, like for example what you need to do if you are flying an airplane and the engines stop. 1) Fly the airplane. 2) Steps to restart the engines. You get the picture. It doesn't seem like rocket science, but the science presented in the book confirms that we are human enough...if we use simple checklists to make sure we don't forget the basics, it saves lives.

The making of the checklist requires an incredible level of comprehension of the steps most likely to be omitted. Many versions must be tested, unnecessary reminders omitted, until the list is streamlined and efficient. So the making of my checklists is beginning, today. Thank you Dr Gawande. If ever someone publishes a book of well-researched basic checklists for the general practitioner, I want a copy.
Tags: books, communication, lists, medicine, mistakes, public health, surgery

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