The Checklist Manifesto_ How to Get Things Right - Atul Gawande [14]
In a complex environment, experts are up against two main difficulties. The first is the fallibility of human memory and attention, especially when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events. (When you’ve got a patient throwing up and an upset family member asking you what’s going on, it can be easy to forget that you have not checked her pulse.) Faulty memory and distraction are a particular danger in what engineers call all-or-none processes: whether running to the store to buy ingredients for a cake, preparing an airplane for takeoff, or evaluating a sick person in the hospital, if you miss just one key thing, you might as well not have made the effort at all.
A further difficulty, just as insidious, is that people can lull themselves into skipping steps even when they remember them. In complex processes, after all, certain steps don’t always matter. Perhaps the elevator controls on airplanes are usually unlocked and a check is pointless most of the time. Perhaps measuring all four vital signs uncovers a worrisome issue in only one out of fifty patients. “This has never been a problem before,” people say. Until one day it is.
Checklists seem to provide protection against such failures. They remind us of the minimum necessary steps and make them explicit. They not only offer the possibility of verification but also instill a kind of discipline of higher performance. Which is precisely what happened with vital signs—though it was not doctors who deserved the credit.
The routine recording of the four vital signs did not become the norm in Western hospitals until the 1960s, when nurses embraced the idea. They designed their patient charts and forms to include the signs, essentially creating a checklist for themselves. With all the things nurses had to do for their patients over the course of a day or night—dispense their medications, dress their wounds, troubleshoot problems—the “vitals chart” provided a way of ensuring that every six hours, or more often when nurses judged necessary, they didn’t forget to check their patient’s pulse, blood pressure, temperature, and respiration and assess exactly how the patient was doing.
In most hospitals, nurses have since added a fifth vital sign: pain, as rated by patients on a scale of one to ten. And nurses have developed yet further such bedside innovations—for example, medication timing charts and brief written care plans for every patient. No one calls these checklists but, really, that’s what they are. They have been welcomed by nursing but haven’t quite carried over into doctoring.
Charts and checklists, that’s nursing stuff—boring stuff. They are nothing that we doctors, with our extra years of training and specialization, would ever need or use.
In 2001, though, a critical care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give a doctor checklist a try. He didn’t attempt to make the checklist encompass everything ICU teams might need to do in a day. He designed it to tackle just one of their hundreds of potential tasks, the one that nearly killed Anthony DeFilippo: central line infections.
On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting in a central line. 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 mask, hat, sterile gown, and gloves, and (5) put a sterile dressing over the insertion site once the line is in. Check, check, check, check, check. These steps are no-brainers; they