The Checklist Manifesto_ How to Get Things Right - Atul Gawande [39]
So what did the study really change? Well, two things, Luby told me. First, “We removed the economic restraint on purchasing soap. People say soap is cheap and most house holds have soap. But we wanted people to wash a lot. And people are quite poor. So we removed that as a barrier.” Second, and just as important, the project managed to make soap use more systematic.
Luby and his team had studied washing behavior in Pakistan, Bangladesh, and other locations around South Asia, and they found that almost everyone washes their hands after defecation. “There are strong ideas about purity in South Asia,” he said. Even when the place to wash is far away, people go and clean their hands over 80 percent of the time, a rate that would put most denizens of airport bathrooms to shame. But the washing was not very effective, the researchers found. Often people did it too quickly. Or they cleaned just the “involved” hand. Or they used ash or mud rather than soap and water.
The soap experiment changed that. The field-workers gave specific instructions on hand-washing technique—on the need to wet both hands completely, to lather well, to rinse all the soap off, even if, out of necessity, as the published report noted, “hands were typically dried on participants’ clothing.” The instructions also got people used to washing at moments when they weren’t used to doing so. “Before preparing food or feeding a child is not a time when people think about washing,” Luby explained. The soap itself was also a factor. “It was really nice soap,” he pointed out. It smelled good and lathered better than the usual soap people bought. People liked washing with it. “Global multinational corporations are really focused on having a good consumer experience, which sometimes public health people are not.” Lastly, people liked receiving the soap. The public health field-workers were bringing them a gift rather than wagging a finger. And with the gift came a few basic ideas that would improve their lives and massively reduce disease.
Thinking back on the experiment, I was fascinated to realize that it was as much a checklist study as a soap study. So I wondered: Could a checklist be our soap for surgical care—simple, cheap, effective, and transmissible? I still had a hard time grasping how to make a checklist that could be both simple and effective for the manifold problems posed by surgery on a global scale. I was uncertain that it was even possible. But several of my colleagues were more sanguine when the idea was raised at the Geneva meeting.
One brought up the experience of Columbus Children’s Hospital, which had developed a checklist to reduce surgical infections. Infection is one of the most common complications of surgery in children. And the most effective way to prevent it, aside from using proper antiseptic technique, is to make sure you give an appropriate antibiotic during the sixty-minute window before the incision is made.
The timing is key. Once the incision is made, it is too late for the antibiotic. Give it more than sixty minutes before the procedure, and the antibiotic has worn off. But give it on time and studies show this single step reduces the infection risk by up to half. Even if the antibiotic is squeezed into the bloodstream only thirty seconds before the incision is made, researchers have found, the circulation time is fast enough for the drug to reach the tissue before the knife breaches the skin.
Yet the step is commonly missed. In 2005, Columbus Children’s Hospital examined its records and found that more than one-third of its appendectomy patients failed to get the right antibiotic at the right time. Some got it too soon. Some got