Surgeons in England to adopt checklists - expect to halve death rate

http://www.independent.co.uk/life-style/health-and-wellbeing/health-news/right-patient-right-limb-two-questions-that-have-almost-halved-death-rate-at-one-hospital-1366705.html

by mhb • 18 years ago

75 65 18 years ago

independent.co.uk

a-priori• 18 years ago

As a member of the general public, I do find it hard to believe this sort of thing isn't done already.

As a victim of a minor surgical mishap myself (general anaesthesia applied when it shouldn't have been), I can definitely believe "incidents" happen all the time.

m0nty• 18 years ago

"I do find it hard to believe this sort of thing isn't done already."

I showed a similar article to my wife (has worked in healthcare for 20+ years) and she said "Oh yes, we do that all the time. Everything has a check-list." So if it makes a difference, I guess it is either mandated for higher-level staff (surgeons and consultants who are often a law unto themselves) or rigidly enforced at all levels.

Also, the study might show bias because people will do the lists if they know it's being assessed for an experiment, but might ignore it on a day-to-day basis.

dcurtis4• 18 years ago

Any doctor who reads the study and sees the 50% reduction in death rate in surgeries and 90% reduction in accidental deaths in the ICU would be negligent to ignore checklists.

If this surgery checklist and the ICU checklist were to be implemented in every hospital, they would save more lives than all new medications introduced in the last five years, combined. Ignoring results like that is just asinine.

yummyfajitas5• 18 years ago

Although I've only had non-trivial procedures done on me once or twice, I've never seen a checklist used.

As for ignoring checklists on a day to day basis, this could be solved by making them a required part of a patient's medical record. That way, doctors are constantly being assessed on the basis of completing a checklist. You could even publish stats on it.

"No checklist, no payment" would also be a good way to enforce it.

rgrieselhuber• 18 years ago

Seems like such a no-brainer for hospitals everywhere.

gravitycop3• 18 years ago

Here's the checklist: http://www.who.int/patientsafety/safesurgery/tools_resources... [PDF]

andreyf2• 18 years ago

Before the patient leaves operating room, make sure that instrument, sponge and needle counts are correct.

And I always thought that was a joke... guess not.

iamelgringo• 18 years ago

That's what OR nurses generally do, count sponges, needles and instruments. They also have to be willing to nose to nose with a crabby surgeon and tell him to re-open the patient and try to find the missing sponge when the count is off

dcurtis4• 18 years ago

Finally.

The idea for a checklist in clinical settings was originally conceived by Peter Pronovost at Johns Hopkins. Last year, Gawande wrote an awesome essay for the New Yorker about the ICU checklists that were attempted in the US (saving hundreds of lives) but eventually cancelled by regulatory authorities-- "If you're changing the way things are done, you need to perform controlled FDA-approved studies."

http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_...

Also, you should read his book Better, which is just page after page of interesting stuff; Atul Gawande is the Malcom Gladwell of medicine, but I think his stuff is far more engaging.

Alex391714• 18 years ago

This combined with How Doctors Think made me realize that our doctors in the US are really no better than witch doctors. In fact in some ways going to a shaman is probably better. They are less likely to cure you, but they are also vastly less likely to kill you by accident. A pretty good tradeoff, considering that medical accidents are the leading cause of death in the US.

http://www.ourcivilisation.com/medicine/usamed/deaths.htm

http://www.ourcivilisation.com/medicine/usamed.htm

And this isn't even counting the fact that none of our antibiotics are working anymore because our medical system sees fit to use over 70% of our total antibiotics produced each year in animal feed.

andreyf2• 18 years ago

medical accidents are the leading cause of death in the US

I thought it was obesity? Or smoking? Or drinking and driving?

none of our antibiotics are working anymore

I don't know, they worked great both when I had lyme disease and when I had bronchitis...

msg2• 18 years ago

That is so not what your link says.

http://en.wikipedia.org/wiki/List_of_causes_of_death_by_rate

The leaders are heart disease, infection, and cancer (from this 2002 table, sourced to WHO).

yummyfajitas5• 18 years ago

While your stats are nonsensical and incorrect, I agree there is a big problem with Witch Doctor, M.D. An experience I once had:

Me: I have nerve pain in my pinky and right side of the forearm. [Shows the doctor where it hurts.]

Dr: You are a programmer. I think you have carpal tunnel syndrome.

Me: I've got pain in my forearm. Also, the ulnar nerve is what connects to the pinky, and that doesn't pass through the carpal tunnel. Are you sure about that?

Dr: Are you questioning my judgement?

I'm happy to say I have found a doctor who does practice the scientific method. Unfortunately, not all do.

omouse2• 18 years ago

I'm going to be as nice and polite as I can be here.

Medical science has had a long history, at least a few hundred years and performs studies/experiments/etc. to make sure that things work.

Witch doctors try random shit and see what sticks to the wall even if it means the patient dies.

Do you see the difference?

If doctors were killing a lot of people, I'm sure journalists would have jumped all over it by now and a lot of doctors would have malpractice suits filed against them.

Antibiotics do work. There have been studies to prove that. This isn't the small-time, this isn't the minor leagues, these pharma-companies are paying a big chunk of change to make sure something useful happens when you take those pills.

If you want lies and deceit, I suggest you go to a "natural" "organic" pharmacy that sells homeopathic garbage.

cturner• 18 years ago

    > This combined with How Doctors Think made me realize
    > that our doctors in the US are really no better than
    > witch doctors.

You don't want to go around saying things like that - you're pushing economics out of their similie that is wholely theirs.

stcredzero2• 18 years ago

...You mean freaking surgeons haven't been using checklists?

People who are about to do something as complicated, delicate, and life-critical as surgery haven't been using checklists!?

FFS! My friends use checklists to go @&#^%%$ camping!

That's almost as bad as doing dynamic language programming without Unit Tests.

:) - for the humor impaired

noonespecial• 18 years ago

As a pilot, I've often contemplated this myself with some sense of sick wonder. Flying a plane is trivial compared to surgery but overlooking something important has equally dire consequences, so all pilots everywhere are taught to always use checklists. It works wonderfully. I just can't imagine going into something so life and death with a "I'm pretty good at remembering everything" attitude!

likpok• 18 years ago

And why shouldn't they do a controlled FDA-approved study? Medicine is a /science/ which means we need to test things, rather than relying on "common-knowledge". If it is as effective as you say, a study should be fairly easy to set up.

dcurtis4• 18 years ago

They did set up a study, informally, like you would do in most sciences for an exploratory experiment.

But it was shut down by the FDA. And to comply with FDA rules (which are designed specifically for drug testing and exploring new surgical processes) it would have taken six years and been too expensive for their budget. So they went to the UK and completed the study in six months for free. The US lost out on that.

mhartl• 18 years ago

You're conflating "scientific studies" with "FDA-approved studies". The former proceed at whatever pace makes sense for medicine and for patients; the latter proceed at the speed of molasses.

xenophanes• 18 years ago

It's great to do a study, but in the meantime can anyone explain how a checklist could be dangerous? If you can't give any ways, then it's silly to ban it for now. This isn't a new medicine with potential unknown effects.

tome• 18 years ago

Although it might not mean much to those outside the UK, this applies to "England and Wales", not just "England".

delano• 18 years ago

Of course, we love the Welsh!

Also, it was a world-wide study that's been implemented in many places. Canada too:

http://www.cbc.ca/health/story/2009/01/14/surgery-check-list...

gaius• 18 years ago

Welsh for checklist is "look you, boyo!" :-)

gravitycop3• 18 years ago

There are three columns on the checklist. Here is the first column:

   SIGN IN


  □ PATIENT HAS CONFIRMED
    • IDENTITY
    • SITE
    • PROCEDURE
    • CONSENT

  □ SITE MARKED/NOT APPLICABLE

  □ ANAESTHESIA SAFETY CHECK COMPLETED

  □ PULSE OXIMETER ON PATIENT AND FUNCTIONING

     DOES PATIENT HAVE A:
  
     KNOWN ALLERGY?
  □ NO
  □ YES

     DIFFICULT AIRWAY/ASPIRATION RISK?
  □ NO
  □ YES, AND EQUIPMENT/ASSISTANCE AVAILABLE

     RISK OF >500ML BLOOD LOSS 
     (7ML/KG IN CHILDREN)?
  □ NO
  □ YES, AND ADEQUATE INTRAVENOUS ACCESS 
     AND FLUIDS PLANNED

gravitycop3• 18 years ago

Here is the second column:

   TIME OUT


  □ CONFIRM ALL TEAM MEMBERS HAVE
    INTRODUCED THEMSELVES BY NAME AND
    ROLE

  □ SURGEON, ANAESTHESIA PROFESSIONAL
    AND NURSE VERBALLY CONFIRM
    • PATIENT
    • SITE
    • PROCEDURE

     ANTICIPATED CRITICAL EVENTS

  □ SURGEON REVIEWS: WHAT ARE THE
    CRITICAL OR UNEXPECTED STEPS,
    OPERATIVE DURATION, ANTICIPATED
    BLOOD LOSS?

  □ ANAESTHESIA TEAM REVIEWS: ARE THERE
    ANY PATIENT-SPECIFIC CONCERNS?

  □ NURSING TEAM REVIEWS: HAS STERILITY
    (INCLUDING INDICATOR RESULTS) BEEN
    CONFIRMED? ARE THERE EQUIPMENT
    ISSUES OR ANY CONCERNS?

    HAS ANTIBIOTIC PROPHYLAXIS BEEN GIVEN
    WITHIN THE LAST 60 MINUTES?
  □ YES
  □ NOT APPLICABLE

    IS ESSENTIAL IMAGING DISPLAYED?
  □ YES
  □ NOT APPLICABLE

danw• 18 years ago

Sounds a bit like Scrum (the agile methodology).

The Surgeon/Anaesthesia/Nursing teams reviewing what has been/needs to be done out loud to each other is similar to a daily stand up and the initial sprint planning meeting in a scrum team.

Saying things out loud to each other makes a social bargain that they will/have been done.

prakash• 18 years ago

Charlie Munger talks about this in his book, Poor Charlie's Almanac.

jsdalton• 18 years ago

Does anyone here use checklists in a similar manner for application development?

abstractbill• 18 years ago

I don't, but people won't die if my software doesn't work.

yellowbkpk• 18 years ago

I don't, but people may die if my software doesn't work.

Our managers do...

tjic• 18 years ago

Given that the death rate used to be 100%, I find it really exciting that the death rate will now be halved.

Downside: all the zombies.

yan• 18 years ago

Ever since I started taking flying lessons, I have been tempted to use checklists for everything else in life.

Jem• 18 years ago

I had v. minor "surgery" before Christmas and I got asked that many questions I started to think they were taking the piss. Based on that, it surprises me that they don't already have this checklist thing in place!

kcy• 18 years ago

I'm a med student and a programmer. I think there are a lot of similarities between these two disciplines.

The body is an incredibly complex system that you or a pathological process can perturb in a variety of ways, just like any other system. The results of those perturbations may be evident immediately or may take a long time to present themselves. The results are output in the form of physical signs and symptoms. The way this particular system works is that there are more potential pathologies than there are physical signs and symptoms, so sometimes you end up with collisions in the pathology to sign/symptom mapping. In these cases you can use instruments like labs, radiological tests, and sometimes invasive methods like surgery to further investigate. These tests are imperfect and are themselves perturbations to the system.

If you can come to a final diagnosis of the underlying pathology using the tools at your disposal (history, physical exam, labs, tests, and procedures) you can then engage in a therapy. The more precise your diagnosis, the more precise your therapy can be. Again, therapies are also perturbations to the system. Ideally these perturbations move the system back into its normal functioning state though they may also cause undesired results that must then be diagnosed and treated.

This entire process takes place within the context of a social interaction that can itself help or hinder. Both doctors and patients have their own social idiosyncrasies that may or may not match up well with each other.

I believe that most physicians operate by generating a gigantic hash table. Essentially they know several patterns of physical signs/symptoms that act as the key. The value is whatever knowledge they have of that disease process. As medical knowledge progresses some physicians update their hash table keys/values with new information, most don't. Almost all physicians update their hash table (i.e. learn) using information gathered in the process of seeing their own patients and recognizing the difference between the predicted outcome and the actual outcome. This is often a subjective process. I think it is because of this approach that most physicians find it hard to believe that medical diagnosis and treatment can be highly systematized and is at least partially such an obvious idea even needs a study to support its use.

daniel-cussen• 18 years ago

In other news: schools to start using Dvorak in 2045.

Surgeons in England to adopt checklists - expect to halve death rate

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