The Checklist Manifesto_ How to Get Things Right - Atul Gawande [44]
It felt kind of hokey to me, and I wondered how much difference this step could really make. But it turned out to have been carefully devised. There have been psychology studies in various fields backing up what should have been self-evident—people who don’t know one another’s names don’t work together nearly as well as those who do. And Brian Sexton, the Johns Hopkins psychologist, had done studies showing the same in operating rooms. In one, he and his research team buttonholed surgical staff members outside their operating rooms and asked them two questions: how would they rate the level of communications during the operation they had just finished and what were the names of the other staff members on the team? The researchers learned that about half the time the staff did not know one another’s names. When they did, however, the communications ratings jumped significantly.
The investigators at Johns Hopkins and elsewhere had also observed that when nurses were given a chance to say their names and mention concerns at the beginning of a case, they were more likely to note problems and offer solutions. The researchers called it an “activation phenomenon.” Giving people a chance to say something at the start seemed to activate their sense of participation and responsibility and their willingness to speak up.
These were limited studies and hardly definitive. But the initial results were enticing. Nothing had ever been shown to improve the ability of surgeons to broadly reduce harm to patients aside from experience and specialized training. Yet here, in three separate cities, teams had tried out these unusual checklists, and each had found a positive effect.
At Johns Hopkins, researchers specifically measured their checklist’s effect on teamwork. Eleven surgeons had agreed to try it in their cases—seven general surgeons, two plastic surgeons, and two neurosurgeons. After three months, the number of team members in their operations reporting that they “functioned as a well-coordinated team” leapt from 68 percent to 92 percent.
At the Kaiser hospitals in Southern California, researchers had tested their checklist for six months in thirty-five hundred operations. During that time, they found that their staff ’s average rating of the teamwork climate improved from “good” to “outstanding.” Employee satisfaction rose 19 percent. The rate of OR nurse turnover—the proportion leaving their jobs each year—dropped from 23 percent to 7 percent. And the checklist appeared to have caught numerous near errors. In one instance, the preoperative briefing led the team to recognize that a vial of potassium chloride had been switched with an antibiotic vial—a potentially lethal mix-up. In another, the checklist led the staff to catch a paperwork error that had them planning for a thoracotomy, an open-chest procedure with a huge front-to-back wound, when what the patient had come in for was actually a thoracoscopy, a videoscope procedure done through a quarter-inch incision.
At Toronto, the researchers physically observed operations for specific evidence of impact. They watched their checklist in use in only eighteen operations. But in ten of those eighteen, they found that it had revealed significant problems or ambiguities—in more than one case, a failure to give antibiotics, for example; in another, uncertainty about whether blood was available; and in several, the kinds of unique and individual patient problems that I would not have expected a checklist to help catch.
They reported one case, for example, involving an abdominal operation under a spinal anesthetic. In such procedures, we need the patient to report if he or she begins to feel even a slight twinge of pain, indicating the anesthetic might be wearing off and require supplementation. But this particular patient had a severe neurological condition that had left him unable to communicate verbally. Instead, he communicated through hand signals. Normally, we restrain the arms