Follow checklists > Prevent disasters
When Atul Gawande made medical checklist taking cue from the airline industry, the morbidity and mortality decreased dramatically (WHO).
Gawande makes a distinction between errors of ignorance (mistakes we make because we don’t know enough), and errors of ineptitude (mistakes we made because we don’t make proper use of what we know).
When there is an error, we quote “to err is human”, but that error may change the life of the person who suffers because of it.
The result of any surgery can be ideal, or acceptable. But acceptable to whom? The term acceptable is used when we cannot achieve ideal outcome, but what is acceptable to a surgeon, is it always acceptable to the patient?
There is a very thin line between a complication and disaster. Usually the disaster is culmination of errors, when each one individually may not be harmful but their cumulative effect results in disaster.
To me, a disaster is a complication that even if corrected, leaves substantial residual deficit that usually is uncorrectable.
Let’s take a case scenario: A 45 year old young male is admitted under you in a limited resources hospital, imagine what all you need to give him an excellent results, what all can go wrong at each stage that will compromise the ideal outcome.
Let us examine what can go wrong in our non-surgical domain that can compromise the outcome and lead to a disaster:
• The staff nurse may be a new one not knowing our instruments.
• There is no stand by generator in case of power failure.
• There is only one C-arm that is 10 years old and has not been serviced for a long time and the company has no mechanic available.
• There are only 3 lead aprons available for your team.
• The pre-op shoot through lateral X-ray that you advised is under exposed, not giving you idea about posterior comminution.
• On table you decide that the patient might require abduction osteotomy, but have not taken consent for the same.
• The implant supplier has forgotten to mention that certain length of implant is not available.
• And finally, the patient is your wife’s younger brother!!!!!!
So, you will agree that to avoid disaster, you not only need to have various surgical plans, but also to have various checklists. (There is no escape route for point no. 8, though!!!!)
Here is a small write-up about checklists in medicine from WHO site.
In medicine, as in aviation, checklists can help ensure consistency and completeness in carrying out complex tasks.
In 1935, two experienced test pilots were killed when the Boeing prototype bomber crashed during a demonstration flight. Test pilots went on to create a checklist that standardized the procedures required to safely operate what later became known as the B-17 bomber.
Under the expert lead of Professor Atul Gawande at the Harvard School of Public Health, WHO Patient Safety has taken the concepts and principles of the aviation checklist and applied them to surgery. The results of a year-long pilot study of the Surgical Safety checklist in eight developed and developing countries were published in January 2009, in the New England Journal of Medicine. This study revealed an overall significant reduction in mortality and morbidity after implementation of the checklist.
Checklists allow complex pathways of care to function with high reliability by giving users the opportunity to pause and take stock of their actions ensuring that nothing has been omitted before proceeding to the next step. The checklist approach has the same potential to save lives and prevent morbidity in medicine that it did in aviation over 70 years ago by ensuring that simple standards are applied for every patient, every time.
We are working to create various checklists for benefit of our members. This will be published at the time of WIROC.
C. J. Thakkar
President, Bombay Orthopaedic Society (20167-18)