Pilots Use Checklists. Doctors Don’t. Why Not?

This is a question Dr. Atul Gawande explores in the December 10 issue of The New Yorker. “The Checklist” is a shocking story, it’s an important story—and it’s also very long. I, of course, would be the last person on earth to criticize someone for “writing long” but it occurs to me that many of HealthBeat’s readers may not have the time to peruse the full nine-page story, so I decided to offer a capsule summary here. (To read the story in its entirety, click here).

Gawande is the author of one of my favorite healthcare books, Complications: A Surgeon’s Notes on an Imperfect Science, and he writes wonderfully well. This piece begins with a riveting tale of a three-year-old who falls into in icy fishpond in a small Austrian town in the Alps. “She is lost beneath the surface for 30 minutes before her parents find her on the bottom of the pond and pull her up.” By then “she has a body temperature of 68 degrees—and no pulse.” A helicopter takes her to a near-by hospital. 
There a surgical team puts her on a heart-lung bypass machine. She now has been lifeless for an hour and a half. Gradually, the machine begins to work. After six hours, her core temperature reaches 98.6 degrees, but she is hardly out of the woods. Her lungs are too badly damaged to function, so the surgeons use a power saw to open her chest down the middle and sew lines to and from an artificial lung system into her aorta and beating heart. “Over the next two days, all of her organs recover except her brain. When a CT scan shows global brain swelling, the team drills a hole into her skull, threads in a probe to monitor cerebral pressure, and adjusts fluids and medications to keep her stable. “

Slowly, over two weeks, she comes back to life. “Her right leg and left arm [are] partially paralyzed.  Her speech [is] thick and slurry.  But by age five, after extensive outpatient therapy, she has recovered her faculties completely. She [is] like any little girl again.” 

“What makes her recovery astounding,” Gawande writes, is “the idea that a group of people in an ordinary hospital could do something so enormously complex. To save this one child, scores of people had to carry out thousands of step correctly; placing the heart-pump tubing into her without letting in air bubbles, maintaining the sterility of her lines, her open chest, the burr hole in her skull; keeping a temperamental battery of machines up and running” all the while “orchestrating each of these steps in the right sequence, with nothing dropped . . .”

This, Gawande says, is what happens in intensive care units, every day of the year, all across the country. “Intensive care medicine has become the art of managing extreme complexity—and a test of whether such complexity can, in fact, be humanly mastered.”

American medicine doesn’t do too badly. “The average stay of an I.C.U.
patient is four days, and the survival rate is eighty-six percent.
[This is something to keep in mind when someone says that we shouldn’t
spend so much money on patients in I.C.U. units during their final days
of life. Eighty-six out of 100 survive—and usually, it’s impossible to
know with any certainty which 14 will die.—M. Mahar] “Going into an
I.C.U. is not a sentence of death,” Gawande notes, “But the days will
be the most precarious of your life.”

The complexity and intensity of the care is astounding. The average
patient in an I.C.U. requires “a hundred and seventy-eight individual
actions per day, ranging from administering a drug to suctioning the
lungs, and every one of them poses risks,” Gawande observes, citing a
study done by engineers who tracked I.C.U. care for 24-hour stretches.
“Remarkably,” the engineers found that the nurses and doctors made
errors in just one percent of these actions—“but that still amounted to
an average of two errors a day with every patient.”

“This is the reality of intensive care,” Gawande adds. “At any point,
we are as apt to harm as we are to heal.” Line infections are common…
I.C.U.s put five million lines into patients each year, and national
statistics show that, after ten days, four percent of those lines
become infected. Line infections occur in eighty thousand people a year
in the United States and are fatal between five and twenty-eight
percent of the time, depending on how sick one is at the start.  . . .
The I.C. U., with its spectacular success and frequent failures,
therefore poses a distinctive challenge: what do you do when expertise
is not enough?”

Gawande then turns to the story of how pilots began making checklists.
“On October 30, 1935, at Wright Air Field in Dayton, Ohio, the U.S.
Army Air Corps held a flight competition for airplane manufacturers
vying to build its next-generation long-range bomber.”  Everyone
thought they knew who would win. Boeing’s “gleaming aluminum-alloy
Model 299” was the clear favorite. “It could fly faster than previous
bombers and almost twice as far. A small crowd of Army brass and
manufacturing executives watched as the Model 299 . . . roared down the
tarmac, lifted off smoothly, and climbed sharply to three hundred feet.
Then it stalled, turned on one wing and crashed in a fiery explosion.
Two of the five crew members died, including the pilot, Major Ployer P.
Hill,” the U.S. Army Air Corp’ chief of flight testing.

The cause of the crash?  Pilot error. “Substantially more complex than
previous aircraft, the new plane required the pilot to attend to the
four engines, a retractable landing gear, new wing flaps, electric trim
tabs . . . and constant-speed propellers whose pitch had to be
regulated with hydraulic controls . . .While doing all this, Hill had
forgotten to release a new locking mechanism on the elevator and rudder
controls. The Boeing model was deemed as one newspaper put it, ‘too
much airplane for one man to fly.’”

Perhaps the pilot should have had more training. “But it was hard to
imagine having more experience and expertise than Major Hill,” Gawande
writes. “Instead, they came up with an ingeniously simple approach:
they created a pilot’s checklist, with step-by-step checking for
takeoff, flight, landing and taxing.”

With that checklist, “pilots would go on to fly the Model 299 a total
of 1.8 million miles without one accident,” Gawande writes.  “The army
ultimately ordered almost thirteen thousand of the aircraft, which is
dubbed the B-17.”

At this point in his narrative, Gawande returns to intensive care,
announcing that “Medicine today has entered its B-17 phase. Substantial
parts of what hospitals do—most notably, intensive care—are now too
complex for clinicians to carry them out reliably from memory alone.
I.C.U. life support has become too much medicine for one person to
fly.”

Could something as simple as a checklist help hospitals? Six years ago,
“a critical-care specialist at Johns Hopkins Hospital named Peter
Pronovost decided to give it a try.”
He started with just one problem—line infections—and wrote out the
steps a health care provider must take to avoid these infections when
putting a line in. “Doctors are supposed to 1) wash their hands with
soap, 2) clean the patient’s skin with chlorhexidine antiseptic 3) put
sterile drapes over the entire patient, 4) wear a sterile mask, hat,
gown and gloves and 5) put a sterile dressing over the catheter site
once the line is in.” It doesn’t sound hard, does it? 

Pronovost then “asked the nurses in his I.C.U. at Johns Hopkins to
observe the doctors for a month as they put lines into patients. “ It
turned out that in more than a third of all cases, doctors skipped at
least one step. The hospital administration than gave the nurses
permission to stop doctors if they saw them skipping a step.

Over the next year: “The results were so dramatic that they weren’t
sure whether to believe them: the ten-day line-infection rate went from
eleven percent to zero. So they followed patients for fifteen more
months. Only two line infections . . . in this one hospital, the
checklist had prevented forty-three infections and eight deaths, and
saved two million dollars in costs.”

Once again, higher quality care and less expensive care go hand in
hand.  Keep this in mind when someone tries to scare you by saying that
under national health care reform, the government will try to lower
health care spending. If the government uses medical evidence to reduce
costs—which is what the Democratic candidates plan to do—we will all be
safer.

Pronovost made other checklists for other procedures and ultimately
“took his findings on the road, showing his checklists to doctors,
nurses, insurers, employers—anyone who would listen.”  But he found few
people interested in adopting the lists. “So far, he’d shown only that
checklists worked in one hospital, Johns Hopkins, where the I.C.U.s
have money, plenty of staff, and Peter Pronovsot waking the hallways to
make sure the checklists are being used properly.”  Gawande explains.

But then he caught a break. In 2003 the Michigan Health and Hospital
Association asked Pronovost to try out three of his checklist in all of
Michigan’s I.C.U.s.   Once again, the results were astounding. Before
the project began “infection rates for I.C.U. patients in Michigan
hospitals were higher than the national average, and in some hospitals
dramatically so . . . Within the first three months of the experiment .
. . Michigan’s infection rates fell so low that its average I.C.U.
outperformed ninety percent of I.C.U.s nationwide. Overall, infection
rates in Michigan had fallen by sixty-six percent.” After eighteen
months, the hospitals saved an estimated $175 million in costs and more
than 1500 lives. “The successes have been sustained for almost four
years,” Gawande notes, “all because of a stupid little checklist.”

In December of 2006, the results were published in The New England
Journal of Medicine.  How many U.S. hospitals have adopted checklists
since? 

None. No doubt, many doctors insist that they don’t need a checklist.
They know what they are doing. They went to Yale. The idea of being
“checked” rankles. But while “the still limited response to Pronovost’s
work may be easy to explain . . .it is hard to justify,” Gawande
writes. “If someone found a new drug that could wipe out infections
with anything remotely like the effectiveness of Pronovost’s lists,
there would  be television ads with Robert Jarvik extolling its virtues
, detail men offering free lunches to get doctors to make it part of
their practice . . .That’s what happened when manufacturers  marketed
central-line catheters coated with silver or other antimicrobilas; they
cost a third more, and reduced infections only slightly—and hospitals
have spent million of dollars on them. But, with the checklist, what we
have is Peter Pronovost trying to see if maybe, in the next year or
two, hospitals in Rhode Island and New Jersey will give his idea a
trial.”

Why? Gawande may be too polite to say this, but the answer seems to me
clear. There is no profit to be made on a checklist. What do you sell?
Any experienced intensive care specialist knows what should be on the
list.  All anyone needs is a few pieces of paper and a pencil.
Pronovost has invented a process for delivering health care—not a new
hi-tech procedure, not a new product. And like Jonas Salk, who invented
the polio vaccine, he is willing to give his idea away for free.

If there were something to sell, Johnson & Johnson or Genentech
would have turned Pronovost and his idea into a new medical
breakthrough long ago. The story would be reported in U.S.A. Today,
trumpeted on the Evening News, splashed on billboards across the
nation. Hospitals would be spending millions on ads bragging that they
had this new breakthrough product: “At Mount Hope, Where We Care About
Your Safety…”

In our for-profit healthcare system, people become truly excited about
an idea when someone sees way to make a fortune. So Merck’s new
vaccine, Gardasil,  that protects against 70 percent of the viruses
that cause cervical cancer has gotten extended play
in the press, on TV, and on Wall Street.  Meanwhile, the Pap Smear—a
test that detects virtually all cases of cervical cancer  and has, in
fact, made this type of cancer a “rare disease” in the U.S., gets
little notice. No national campaign to make sure every woman gets
annual Pap Smears. It’s not a high-profit procedure.

In the U.S. the idea that the point of healthcare is better health
seems to have been lost in the rush to make money. As Harvard’s Dr.
Arnold Relman wrote in the most recent issue of JAMA,
ours is “the only health system in the world” where “investors and
business considerations play such an important role. In no other
country are the organizations that provide medical care so driven by
income and profit-generating considerations.” 

Recently, Gawande asked Pronovost how much it would cost to do for the
whole country what he did for Michigan, and how long it would take. The
answer: about two million dollars and two years—“if the country wanted
it.”

“So far,” Gawande writes, “it seems that we don’t. The U.S. could have
been the first to adopt medical checklists nationwide.” Instead Spain,
of all places, is beating us to the punch. While New Jersey mulls the
idea over, Spain has already signed up for Pronovost’s program.

Finally, Gawande circles back to the beginning of his story, and
confides that he recently spoke to Markus Thalmann, “the cardiac
surgeon on the team that saved the little Austrian girl who had
drowned.”  In the context of Gawande’s larger story, what he learned is
almost unbearably ironic: “a checklist had been crucial to her
survival.”  The team at the Austrian hospital faces three to five
patients like the little girl every year, often the victims of an
avalanche. For years, they could never save them—until Thalmann and a
couple of colleagues made and distributed a checklist. The rescue of
the three-year-old girl was their first success with the checklist in
place. Since then, it has saved other lives.

But it seems that this is the sort of thing that can happen only in a
small town in Austria. Or in Spain. Not in the U.S.  In the U.S., no
one is going to tell us how to practice medicine.

13 thoughts on “Pilots Use Checklists. Doctors Don’t. Why Not?

  1. Not only is there no profit in a checklist — there are billings in treating errors.
    If a pilot crashes a plane the airline suffers a huge loss. Their incentive is to keep that valuable capital in working order — and hopefully to protect their passengers as well!
    The blog-o-sphere was full of criticisms this fall when CMS announced they will not pay for certain hospital errors. The howls of what this would do to care were rampant — yet it is this kind of “loss avoidance” that will turn checklists into used tools.

  2. Relman says the US is“the only health system in the world where investors and business considerations play such an important role. In no other country are the organizations that provide medical care so driven by income and profit-generating considerations.”
    Don’t worry Dr Relman and Maggie. Believe me- we are hitting bottom.
    Checklists will be routine in 3-5 years.
    Arrogant surgeons and “MDieties” practicing in intensive care units will be banished from the profession.
    Dr. Rick Lippin
    http://medicalcrises.blogspot.com

  3. Ginger and Rick–
    Ginger-
    Unfortunately what you say is true.
    If a pilot makes a mistake, there is good chance that he will die, along with his passengers.
    This makes pilots (and other members of the crew)
    take safety very personally.
    Research shows that in hospitals, staff tend to be not quite as vigilant about errors. Only the patient dies–and in hospitals, death is a commonplace event. (Also, it’s often not clear that the error killed the patient, though an infection or another “adverse event” may have played a role . . .)
    So an article published in Health Affairs reported, hospital staff don’t have quite the same sense of urgency about avoiding errors. It’s not that they are uncaring, but they live in a world where people are dying all of the time.
    By contrast, an airline crash is seen as a caststrophe for crew as well as passengers. . .
    Rick– I’m not quite sure what you’re saying . .Are you against checklists?

  4. My two takeaways from this article are as follows:
    1. In the Johns Hopkins case, empowering nurses to speak up when a doctor skipped a step on the checklist contributed significantly to reducing the number of infections. It is critical for hospital management to back the nurses up when and if arrogant doctors react badly and threaten to get them fired.
    2. Public reporting of hospital infection rates in an easily accessible, user friendly format would likely spur widespread adoption of checklists as low infection rates become one of the ways that hospitals attempt to differentiate themselves from their competitors to attract patients. Sunshine (transparency, in this case) is a great disinfectant.

  5. Maggie;
    I am definitely FOR checklists or anything that will improve patient safety.
    To me the medical errors issue and the issue of the ill health of US health care workers ranks up there as our nation’s most egregious and embarrasing cultural paradoxes.
    Rick Lippin

  6. Barry and Rick–
    Barry– I agree completely that giving nurses the authority to speak up (much the way co-pilots and other members of an airplane crew are expected to speak up if the pilot is making an error) is key.
    Again, it’s all about recognizing that medicine is a team sport. Today, it’s so complex no one person can remember everything all of the time. People need to have each other’s back.
    This team approach needs to be taught in Med school. I wonder if in some classes, med students and nurses shouldn’t be taught together at universities that have both a nursing school and a med school.
    Rick– I thought you must be in favor of checklists . . . I misunderstood your wording.

  7. This immediately brought to mind the story of Ignaz Philipp Semmelweis. He instituted the practice of handwashing in obstetrical practice in Austria in the mid 1800’s. His procedure drastically decreased the infection rate and death of women. However, it took years for handwashing to be adopted.

  8. Michael–
    Yes, and apparently it is still taking years to get everyone to adopt hand-washing all of the time!

  9. I always laugh when I hear about the analogy of airline pilots to medicine.
    The comparison would be apt if the average stay of a person in a hospital was 3 hours and the patient panel was an uniform as the control panel on an airplane.
    An airplane has a group of 4-6 people for a 3 hour time slot. In a hospital environment, a typical doctor carries about 25 patients, each with a separate nurse, nurse tech, etc. So you are not talking about one team, you are talking about 25 different teams PER DOCTOR, PER SHIFT.
    In terms of checklists, in order for it to work you need a team approach to every procedure. So in the case of a central line, the doc puts hte order into the computer. The patient’s nurse is paged. They meet at the bedside with the checklist and the doc and the nurse make sure every step is checked off appropriately.
    I also think theere should be mandated reporting of safety outcomes at hospitals nationwide.
    P.S. I dont think the nurses will be as excited as you guys think they are to be doign this double checking stuff. They are very hesitant to increase their workload unless they get more staffing or a higher paycheck. Anybody whose worked in a hospital knows that nurses set more hospital policy than doctors do.

  10. “This team approach needs to be taught in Med school. I wonder if in some classes, med students and nurses shouldn’t be taught together at universities that have both a nursing school and a med school.”
    Whats that going to do? Nursing and medicine are very different skill sets. I guess you could bring them together to do some random “team building” exercises, but that stuff is overrated and wont translate to any improved teamwork in a real-time hospital setting. To accomplish that you need changes in hospital policy backed up with enforcement.

  11. Joe Blow-
    Interesting comments.
    Let me ask a couple of questions:
    First, are we talking about a doctor who is a hospitalist, or someone with privileges at the hospital?
    Is it easier to co-ordinate care with a hospitalist?
    Why would a doctor’s 25 patients each have a separate nurse? (Are we talking about patients in different wards? If the doctor is a specialist I would assume most of his patients would be in one or two –or at most three–wards, so why couldn’t he be paired with one nurse per ward per shift?)
    What type of “changes in hospital policy backed up with enforcement” are needed?
    In terms of whether nurses would be happy about checklists. . . IHI (the Insitute for Health care Improvement) has found that virtually everyone on a hospital staff is happier when quality is improved and care is co-ordinated. The big frustration for nurses is the chaos in many hospitals which creates great pressure–constant fear of making mistake, etc.
    Also nurses welcome the idea of being given the power to speak up. . .

  12. Are hospital protocols not checklists in certain ways? I know when I get a patient with a certain diagnosis, certain things are “checked off” by the MDs.
    MD’s are also throwing fits, because they say that these protocols are leaving them less room to practice medicine, everything is the same for each patient.
    Also, give medicare a chance to implement checklists, and they will simply not reimburse for a procedure if there’s not documentation that a checklist of sorts wasn’t done. (which Im sure will be up to nurses to document doctors procedures.)
    Where is the line drawn? What would checklists be made for, if they were implemented nationally? Im afraid medicine will become too dependent on these checklists.

  13. Morgan-
    A checklist is a piece of paper that lists exactly what needs to be done before starting surgery– or during some other procedure to prevent errors.
    Make sure it’s the right patienit. (Check name on wristband).
    Make sure it’s the right operatoin.
    Right site.
    Review info on chart from pre-surgery work-up regarding allergies, potential complications etc.
    Do some specific things to insure sterility and reduce possiblity of infection.
    It’s surprisngly easy to slide over one of the items on the list.
    That’s how hospitals wind up operating on the wrong patient, the wrong leg, etc.
    That’s how we have way too many infections and complications following surgery.
    Typically, everyone in the surgical team thought someone else “checked” that point on the list.
    By reading it aloud so that everyone sees and hears that each point is being “checked” we avoid those mistakes.
    Yes, I think it would be excellent if Medicare required a checklist–signed by both a doctor who was present and at least one nurse who was presesnt before surgeries and other procedures that often lead to infections.
    It’s a simple enough thing to do–and lives would be saved.