The Checklist Manifesto_ How to Get Things Right - Atul Gawande [15]
The next month, he and his team persuaded the Johns Hopkins Hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask the doctors each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder (“Um, did you forget to put on your mask, doctor?”) to more forceful methods (I’ve had a nurse bodycheck me when she thought I hadn’t put enough drapes on a patient). But many nurses aren’t sure whether this is their place or whether a given measure is worth a confrontation. (Does it really matter whether a patient’s legs are draped for a line going into the chest?) The new rule made it clear: if doctors didn’t follow every step, the nurses would have backup from the administration to intervene.
For a year afterward, Pronovost and his colleagues monitored what happened. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from 11 percent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths and saved two million dollars in costs.
Pronovost recruited more colleagues, and they tested some more checklists in his Johns Hopkins ICU. One aimed to ensure that nurses observed patients for pain at least once every four hours and provided timely pain medication. This reduced from 41 percent to 3 percent the likelihood of a patient’s enduring untreated pain. They tested a checklist for patients on mechanical ventilation, making sure, for instance, that doctors prescribed antacid medication to prevent stomach ulcers and that the head of each patient’s bed was propped up at least thirty degrees to stop oral secretions from going into the windpipe. The proportion of patients not receiving the recommended care dropped from 70 percent to 4 percent, the occurrence of pneumonias fell by a quarter, and twenty-one fewer patients died than in the previous year. The researchers found that simply having the doctors and nurses in the ICU create their own checklists for what they thought should be done each day improved the consistency of care to the point that the average length of patient stay in intensive care dropped by half.
These checklists accomplished what checklists elsewhere have done, Pronovost observed. They helped with memory recall and clearly set out the minimum necessary steps in a process. He was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions. In a survey of ICU staff taken before introducing the ventilator checklists, he found that half hadn’t realized that evidence strongly supported giving ventilated patients antacid medication. Checklists, he found, established a higher standard of baseline performance.
These seem, of course, ridiculously primitive insights. Pronovost is routinely described by colleagues as “brilliant,” “inspiring,” a “genius.” He has an M.D. and a Ph.D. in public health from Johns Hopkins and is trained in emergency medicine, anesthesiology, and critical care medicine. But, really, does it take all that to figure out what anyone who has made a to-do list figured out ages ago? Well, maybe yes.
Despite his initial checklist results, takers were slow to come. He traveled around the country showing his checklists to doctors, nurses, insurers, employers—anyone who would listen. He spoke in an average of seven cities a month. But few adopted the idea.
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