If Doctors Flew Airplanes... A Review of "The Checklist Manifesto"

Atul Gawande's, The Checklist Manifesto, is a discussion of an industry's difficulty in addressing patient safety. It is also a clear and reasonable path to patient safety improvement.

The primary thesis of this book is that medicine could dramatically improve patient safety if it borrowed and implemented checklist methodologies that are used with stellar success in industries such as aviation and large-scale construction.

One of the most distressing points the book makes is regarding simple handwashing. Almost two hundred years after it was statistically proven that handwashing saves countless lives, clinicians are still struggling with compliance (in fact, a May 2010 study indicates that clinicians complied with handwashing guidelines less than half of the time). According to Gawande, this lack of discipline extends into the Operating Room, where he describes complex tasks that must be highly choreographed between many professionals in order to produce positive outcomes that have no script or checkpoints.

Gawande further points out that basic process definition–control and learning–which is common to every industry engaged in complex systems, has not really taken hold in the practice of medicine. Those who do master the checklist, such as the Swiss clinic described in the book that saved a drowning child, were awe-inspiring. They had drilled for the event like an Olympic team and when it came time, the training saved the child.

Gawande notes inconsistencies in thinking about safety that are bewildering. For example, ninety-three percent of physicians surveyed wanted checklists used if they were on the operating table, while twenty percent question their value when operating themselves.

What is surprising to a layperson is that process control appears to be at the clinician's discretion. This would be akin to every commercial pilot having their own landing approach protocol -- or none at all.

Gawande's analytical strength is his lack of "not invented here" or "we are different" mentality. He is not above asking a construction foreman or engineer how high quality is achieved in their respective disciplines.

I became interested in what the impact is of our inability to share knowledge across industry segments -- especially segments that involve many people and complex systems. To bring things into grim perspective, let's look at the mortality rates in three industries:  

• Automotive: According to the Nation Transportation Safety Board, there are about 37,000 fatalities involving automobiles annually in the U.S.
• Medicine: According to the Institute of Medicine, about 100,000 people die from medical errors annually in the U.S.
• Aviation: According to the Nation Transportation Safety Board, there were no U.S. commercial airline fatalities in 2007 and 2008, but there were 45 fatalities in 2009 from a single crash.

Even when we apply a denominator consisting of the number of people involved in each industry yearly, the message is the same.

From a quality and safety perspective, Aviation and Medicine have much in common. In both fields, safety is largely determined by the individual and/or collective decisions of those operating the process. There is one significant difference: the pilot rides in the front of the plane.

What happens when Aviation checklist standards are applied to medicine? Gawande sites an eight-city, 4,000 patient study using surgical checklists that produced a 36% drop in complications and a 47% percent drop in fatalities. The study was sponsored by the World Health Organization and involved locations around the globe under varying conditions and across many surgical procedures.

Despite the efficacy, Gawande points out resistance remains, much like hand washing. For the most part, we are left to speculate why the industry wouldn't embrace a process so obviously successful.

Reaction to The Checklist Manifesto has not been neutral. Steve Levitt, co-author of Freakonomics, said this book "honestly changed the way I think about the world. It is the best book I've read in ages." The book should not only change our outlook, but should inspire a little outrage regarding our own intransigence toward the simplest of life saving innovations.

At SironaHealth our registered nurses use guidelines to triage patients. Guidelines are a form of checklist. They are essential to setting standards for patient safety from which we can measure the quality of our decisions. They are being constantly refined by their authors, Dr. Barton Schmitt and Dr. David Thompson, based on feedback from millions of patient interactions. I can't fathom the chaos and process blindness that would exist without them.

Photo credit: http://gawande.com/the-checklist-manifesto