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Pilots Do It: Do Your Surgeons???

July 13, 2008
by Mark Hagland
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So, here’s a question: Would you fly on an airline whose pilots didn’t follow routine checklists before takeoff? A few decades ago, the question wasn’t purely academic. Major airlines regularly operated based on the experience of individual pilots. But a series of spectacularly horrible plane crashes transformed the airline industry worldwide. And today, no pilot would think of lifting off a runway without following a series of consensus-driven steps and checking off specific tasks verbally or electronically. So, presumably, your answer is, no, you wouldn’t tolerate the idea of flying an airline whose pilots didn’t follow prescribed checklists, since the need for them has become universally demonstrated and recognized.

So how about checking in to see whether your surgeon follows a checklist before, during, and at the conclusion of, your surgery? Nationwide, very, very few surgeons do so as of yet. But the question might well have been asked of the Boston surgeon practicing at a highly prestigious academic medical center who last week performed a wrong-side surgery, and whose case received broad local and regional coverage. What’s more, in the first five months of this year, five wrong-side surgeries have already been performed in Massachusetts, one of the states with the most active and robust quality reporting environments in the country.

Encouragingly, on the opposite coast, surgery teams at the University of Washington Medical Center in Seattle recently adopted the WHO/SCOAP Surgical Safety Checklist, developed by the World Health Organization’s “Safe Surgery Saves Lives” initiative and the Surgical Care and Outcomes Assessment Program.

Some of the items on the checklist are so straightforward as to seem self-evident, such as “Surgeon, anesthesia professional and nurse verbally confirm patient name, ID band, site, procedure, position,” “Antibiotic prophylaxis given in last 60 minutes,” and, “After surgery, nurse confirms instrument, sponge and needle counts correct.” Unfortunately, as we all know, patients continue to be rolled into post-surgical recovery with sponges and scalpels inside their bodies; wrong sides and organs continue to be operated on; and antibiotic and anesthesia errors continue.
As the head of the SCOAP project, Dr. David Flum, told The Seattle Times late last month, “It seems totally obvious. They’ve been doing this in aviation for four decades, yet it's been totally absent in health care because there's no system to make sure it happens."
The analogy may not be perfect, but CIOs might want to think of themselves as conceptually sitting in the cockpits of airplanes with pilots, the next time they consider how important the development of surgical information systems and other automated tools will be to surgery going forward. No, they’re not there in the actual surgeries alongside the surgeons; but the tools whose implementation they lead are going to save lives and reduce medical errors, and are very much needed, along with verification and safety procedures and policies that will, when implemented intelligently in tandem with good information systems, help protect patients from harm.

The bottom line? We in healthcare are moving into a new era of accountability, transparency, and high demands from the purchasers, payers and consumers of healthcare. CIOs can be heroes not only to clinicians, but also to patients and families, as they help clinicians perform optimally under the always-challenging conditions of surgical care. Had the Boston surgeon been working within a checklist- and verification procedure-based framework, it’s less likely he would have performed a wrong-side surgery; and the patient, the doctor, the whole clinical team, and the hospital would all have been better off as a result.

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Comments

Great post. You've uncovered or exposed or re-exposed a great truth. Almost everyone prefers to not use checklists.

I'm sure the surgeons you described were aware of checklists as a tool. This is one of the barriers to incorporation of EbM into practice and more effective use of HCIT with less unintended consequences. (see blog post on EbM: http://healthcare-informatics.com/ME2/dirmod.asp?sid349DF6BB879446A1886B... )

Readers interested in the topic or fans of Atul Gawande should read this:

http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?prin...

It's a detailed story of Dr Peter Pronovost's checklist experience in ICUs (bottom line - checklists are very good and needed). Dr Gawande in this New Yorker article elaborates a dramatic aviation story which Mark referenced, and touch on the odd policy politics in healthcare. The article is less than a year old. It's inspirational highly suitable to print and hand to your CXOs.

Lastly, to Mark's point on the CIO's opportunity, I strongly agree and many (most?) talented CIOs have been created real-time reports whose structure was exactly a checklist. Some deployed to paper, some to PC, some to PDA.

The administrative ones we call patient lists, or when expansive, rounds reports. Their underlying structure, what's included and its sequence exactly constitutes a check list. And, in the patient-specific context, checklists for safe medication use (like Coumadin, see my 'Homework First' article in 7/2008 HCI for elaboration, or tPA are high value examples), and broader process checklists, like pre-op checklists. Case Management has been a rich area for customized checklists in hospitals for case managers. Huge efficiencies in identifying and addressing those issues in real time. Most organizations wont publicly talk about these deployed uses for checklists for obvious reasons. Just like how they use rules engines!

The 'Homework First' article can be found here: http://healthcare-informatics.com/ME2/dirmod.asp?sid&nm&typePublishing&m...

It's only been in the last five years or so that the HCIT barriers to deploying and iterating checklists have been coming down. Historically, knowing where the data really is, getting to it without an abusive performance impact on the technology platform, local skills, and available IT FTE hours and social skills, together, have made it nearly impossible to get the checklists described above. Many large vendors, shadow HIS vendors, and home-grown solutions have lowered the threshold to wider-spread use of checklists. Per the references in this post, there is clearly a need for HCIT to be part of the solution to these real clinical problems.

A fine quality educational blog! I like the way blogger presented information regarding the concerned subject. Thanks for posting such a nice blog.

Mark Hagland

Editor-In-Chief

Mark Hagland

@hci_markhagland

www.healthcare-informatics.com/blog/mark-hagland

Mark Hagland became Editor-in-Chief of Healthcare Informatics in January 2010. Prior to that, he...