Some years ago, just before going into surgery, a loved one asked me to place a sticky note on one of her knees so that the surgeon wouldn’t mistakenly operate on the other. I thought it was a bit too aggressive and didn’t. But I made sure to remind the surgeon and the lead nurse in person, looking into their eyes, that it was the right knee, not the left one, in half-jest.
Apparently, we weren’t the only ones who should worry about this, as The Independent reports:
Surgeons in England and Wales will be ordered today to carry out a safety checklist before every operation they perform, after a study showed it cut surgical deaths and complications by a third.
Described as the biggest clinical innovation in 30 years, the checklist is based on a set of seemingly banal questions but is set to become as essential to daily medicine as the stethoscope. In Britain alone, the new procedure could save hundreds of lives a year and 80,000 complications.
Estimated operations around the world approaching 250,000 per year, the stakes are enormous:
Atul Gawande, an American surgeon and associate professor at the Harvard School of Public Health, who led the study, said work was under way on further checklists for maternity and childbirth (to be published this year), heart disease, pneumonia, HIV and mental health. “It is one of those simple, unbelievably powerful ideas that will have an impact across medicine. Surgeons had assumed that doing well for patients was mostly about their skill. But there is now too much technology and too many patients for one person to deal with.”
He added: “When I talk to clinicians, they say: ‘we already do this stuff.’ The answer is: we are good at doing it most of the time, but we are not good at doing it all the time. We found some members of the team felt they were such low agents, they only felt responsible for their corner. Being allowed to say who they were [one item on the checklist] and hear the surgeon say what he expected made them feel part of the team. When you are not given a voice you turn your brain off.”
Over the years, I have trained and mentored many designers, developers and analysts. I’ve found it quite difficult to get them to first create and then methodically follow checklists. Some of the most egregious and preventable mistakes often result from failing to follow just a few checkable items. Not all mistakes harm people but end up wasting a lot of time, like when a developer was nearly in tears after spending an entire afternoon trying to debug an XML-to-PDF-to-print utility. The printer wasn’t on.
I have nearly given up on homo sapiens reliably executing checklists. So my design and management practice has moved on to analytics/rules driven system design where such failure is assumed and thus automated out of existence, without hopefully making the system too brittle. It’s of course harder to design that way up-front, but the pay-off is undeniably worth it, time after time .