The usefulness of being methodical

2009-01-27

in Geek stuff, Science

'Justice' stonework

Whenever I need to wake up early in order to catch a bus or train, I make sure to lay everything out in a clear and sequential manner. That is the most effective way of not forgetting critical items, while also not wasting too much time checking and re-checking things. While, in my case, it is early-morning brain woolliness that makes such clear sequencing valuable, there is evidence that simple lists and straightforward procedures can also serve a useful purpose in situations where complex and demanding tasks are undertaken, sometimes making it too easy to forget a seemingly small but crucial step. Flying airplanes and performing surgery are examples. Indeed, it seems that the pilots might be able to teach some useful techniques to the men and women with the scalpels.

Some recently published research has shown that a simple World Health Organization (WHO) checklist (PDF) is highly valuable for preventing surgical mishaps. The British National Patient Safety Agency found that the use of the checklist (which includes simple items like having the surgical staff confirm the patient, site, and procedure to be performed) can cut deaths by over 40% and complications by over a third. The finding is especially impressive due to the sample size examined: 7,688 patients, 3,733 before the checklist was implemented, and 3,955 afterwards. The patients were located in a diverse collection of countries, including the United States, Canada, the United Kingdom, New Zealand, Jordan, India, the Philippines, and Tanzania. Clearly, surgeons worldwide tend to overlook the same things.

It’s a curious quirk of human nature that someone can be both capable of performing advanced cardiac surgery and capable of forgetting a sponge inside the patient’s body while sewing them up. Hopefully, simple tools like the WHO checklist will help the former to occur more successfully without the danger of the latter. In a less specific context, it is worth remembering the value of simple tools that produce welfare improvements quite disproportional to their cost or difficulty of use.

{ 13 comments… read them below or add one }

Milan January 27, 2009 at 9:08 am

This previous post is related:

How not to lose things
January 31, 2008

Anon January 27, 2009 at 9:15 am

A 40% reduction in deaths? Do you think the surgeons would be terribly offended if I brought my own copy of this checklist and asked that it be used, should I ever require surgery? Even if it would insult them a bit, it might be worth it.

R.K. January 27, 2009 at 10:48 am

“cut deaths by over 40% and complications by over a third”

That is quite an improvement! Hopefully, using these kinds of checklists will become standard practice in hospitals all over.

Alena January 27, 2009 at 11:25 am

When I worked as a family aid at Children’s Hospital in Montreal, I saw patients who were brought in by ambulance into medical or surgical emergency. There was always a sense of panic, blood, emotion and a general feeling of loss of control. Many mistakes were made in this environment and procedures were not always followed. In many ways, that is the nature of emergency. “Bloodletting & Miraculous Cures,” by Vincent Lam does a good job of portraying lapses of order in a hospital setting.

oleh January 27, 2009 at 12:22 pm

This is an area I need help in.

I have a habit of misplacing items such as wallets and phones. Alena’s suggestion that I get a male purse has served me well. I try to put my wallet, phone and blackberry in my “murse” and that serves me well.

Also I do better when I use Milan’s card system for keeping track of things to be done and ideas.

Yes setting out my cycle clothes in the morning before a early am cycle seems to help as well.

Milan January 27, 2009 at 12:26 pm

Do you think the surgeons would be terribly offended if I brought my own copy of this checklist and asked that it be used, should I ever require surgery? Even if it would insult them a bit, it might be worth it.

Personally, I would be tempted to ask for this too. That being said, I don’t know how often you get to talk with your surgeon before they open you up. It doesn’t seem that my brother got the chance to do so before his appendectomy. Also, surgeons may refuse to diverge from their hospital’s standard procedures, even if those do not include a comparable checklist.

Probably, it makes more sense to encourage the use of such lists at the institutional level than it does to try and impose them at the individual level.

Milan January 27, 2009 at 12:29 pm

There was always a sense of panic, blood, emotion and a general feeling of loss of control.

After traumatic accidents, I can certainly see why this would be the case. For routine surgery, however, one would expect it to be possible for things to be pretty well sequenced and orderly.

Milan January 27, 2009 at 12:30 pm

Also I do better when I use Milan’s card system for keeping track of things to be done and ideas.

The ‘Hipster PDA’ system is not of my invention. It comes from 43folders.com

Sarah January 28, 2009 at 2:20 pm

Perhaps one could make the use of such checklists by surgeons a condition of providing informed consent as a patient? Of course that would work best for scheduled non-emergency operations, since it seems likely that the hospital would refuse and you’d need to name and shame them in the media in order to get anywhere. I also wonder whether any hospital that refused might be liable to legal challenges for negligence (must one suffer a harm as a result of the act for it to be negligent, or is the act merely contrary to good practice and likely to cause harm?)

Not ‘the utility of being methodical’? Why not?

. March 17, 2009 at 10:04 pm

Leaving Infants in the Car
March 17, 2009

The human brain, he says, is a magnificent but jury-rigged device in which newer and more sophisticated structures sit atop a junk heap of prototype brains still used by lower species. At the top of the device are the smartest and most nimble parts: the prefrontal cortex, which thinks and analyzes, and the hippocampus, which makes and holds on to our immediate memories. At the bottom is the basal ganglia, nearly identical to the brains of lizards, controlling voluntary but barely conscious actions.

Diamond says that in situations involving familiar, routine motor skills, the human animal presses the basal ganglia into service as a sort of auxiliary autopilot. When our prefrontal cortex and hippocampus are planning our day on the way to work, the ignorant but efficient basal ganglia is operating the car; that’s why you’ll sometimes find yourself having driven from point A to point B without a clear recollection of the route you took, the turns you made or the scenery you saw.

. August 25, 2010 at 2:04 pm

Look-Alike Tubes Lead To Hospital Deaths

Hugh Pickens writes “In hospitals around the country, nurses connect and disconnect interchangeable clear plastic tubing sticking out of patients’ bodies to deliver or extract medicine, nutrition, fluids, gases or blood — sometimes with deadly consequences. Tubes intended to inflate blood-pressure cuffs have been connected to intravenous lines leading to deadly air embolisms., intravenous fluids have been connected to tubes intended to deliver oxygen leading to suffocation, and in 2006 a nurse at in Wisconsin mistakenly put a spinal anesthetic into a vein, killing 16-year-old who was giving birth. ‘Nurses should not have to work in an environment where it is even possible to make that kind of mistake,’ says Nancy Pratt, a vocal advocate for changing the system. Critics say the tubing problem, which has gone on for decades, is an example of how the FDA fails to protect the public. ‘FDA could fix this tubing problem tomorrow, but because the agency is so worried about making industry happy, people continue to die,’ says Dr. Robert Smith.” This reminds me of the sort of problem that Michael Cohen addressed in a slightly different medical context (winning a MacArthur Foundation grant) a few years ago.

. April 29, 2011 at 7:22 pm

On Tuesday, I wrote about a new technological system that might help hospitals to accurately track whether health care workers are washing their hands, and remind them to do so in real time. The reason hospitals might want to spend the money to install such an expensive fix is that so far, very few hospitals have been able to get their hand-washing rates above 50 percent.

Health care workers’ failure to clean their hands is the most important cause of hospital-based infections, which are the fourth-leading cause of death in America and cost our health care system some $40 billion a year.

Routine hand-washing before and after seeing each patient — the type of hand hygiene these technological systems are targeting — is likely the most resistant to improvement. It has to be done dozens or hundreds of times a day by busy health care workers who may be doing two or three things at once and have their hands full of supplies.

. August 15, 2018 at 4:46 pm

As for aviation, over the past decade the use of checklists like those used by pilots has become commonplace. Before cutting a patient open, surgeons, anaesthetists and nurses go through a simple exercise to ensure they have the right equipment (and the right patient), know the operation to be performed and understand the risks.

In 2009 another study for the WHO suggested that a simple checklist in eight hospitals in cities in eight countries cut the rate of death during surgery from 1.5% to 0.8%, and that of complications from 11% to 7%. Since then checklists have become ubiquitous in Danish, French, Irish, Dutch and British hospitals, and used about half of the time in developing countries.

But, again, there are very few randomised studies to bear this out. And, often, medics know procedures are under evaluation, which may change behaviour. Some of the more rigorous studies are disappointing. One published in 2014, of 200,000 surgical procedures in 101 hospitals using checklists in Ontario, Canada, found no link to improved outcomes. A recent study of the use of checklists in obstetric care in India again found no firm link between their introduction and reduced deaths of infants or new mothers. The reasons for these disappointing results “are primarily social and cultural”, suggested an article in the Lancet medical journal co-authored by Charles Bosk, a medical sociologist. He argues that many surgeons feel that using a checklist infantilises them and undermines their expertise.

So, more promising may be approaches that do not ask much of doctors themselves. Over the past few years behavioural scientists have begun to try to nudge doctors to make better decisions by studying and acting upon their inherent biases. “Default bias”, the tendency to accept the status quo, is powerful in clinical settings. Most doctors, for example, follow the prescription dosages suggested by electronic medical-record (EMR) software. The same is true of the default settings on medical kit. Research in ICUs has shown that, on their standard settings, artificial ventilators can put huge pressure on the lungs, tearing tissue and provoking inflammation. Tweaking ventilators so that they have a “low tidal volume” setting is often better, but many doctors do not have the time to make the necessary calculations. In a study published in 2016, doctors at the University of Bristol showed that, just by switching the default settings on the machine, patients received safer ventilation.

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