The Checklist Manifesto_ How to Get Things Right - Atul Gawande [54]
Sometimes, though, failures are investigated. We learn better ways of doing things. And then what happens? Well, the findings might turn up in a course or a seminar, or they might make it into a professional journal or a textbook. In ideal circumstances, we issue some inch-thick set of guidelines or a declaration of standards. But getting the word out is far from assured, and incorporating the changes often takes years.
One study in medicine, for example, examined the aftermath of nine different major treatment discoveries such as the finding that the pneumococcus vaccine protects not only children but also adults from respiratory infections, one of our most common killers. On average, the study reported, it took doctors seventeen years to adopt the new treatments for at least half of American patients.
What experts like Dan Boorman have recognized is that the reason for the delay is not usually laziness or unwillingness. The reason is more often that the necessary knowledge has not been translated into a simple, usable, and systematic form. If the only thing people did in aviation was issue dense, pages-long bulletins for every new finding that might affect the safe operation of airplanes—well, it would be like subjecting pilots to the same deluge of almost 700,000 medical journal articles per year that clinicians must contend with. The information would be unmanageable.
But instead, when the crash investigators issued their bulletin—as dense and detailed as anything we find in medicine—Boorman and his team buckled down to the work of distilling the information into its practical essence. They drafted a revision to the standard checklists pilots use for polar flights. They sharpened, trimmed, and puzzled over pause points—how are pilots to know, for instance, whether an engine is failing because of icing instead of something else? Then his group tested the checklist with pilots in the simulator and found problems and fixed them and tested again.
It took about two weeks for the Boeing team to complete the testing and refinement, and then they had their checklist. They sent it to every owner of a Boeing 777 in the world. Some airlines used the checklist as it was, but many, if not most, went on to make their own adjustments. Just as schools or hospitals tend to do things slightly differently, so do airlines, and they are encouraged to modify the checklists to fit into their usual procedures. (This customization is why, when airlines merge, among the fiercest battles is the one between the pilots over whose checklists will be used.) Within about a month of the recommendations becoming available, pilots had the new checklist in their hands—or in their cockpit computers. And they used it.
How do we know? Because on November 26, 2008, the disaster almost happened again. This time it was a Delta Air Lines flight from Shanghai to Atlanta with 247 people aboard. The Boeing 777 was at thirty-nine thousand feet over Great Falls, Montana, when it experienced “an uncommanded rollback” of the right No. 2 engine—the engine, in other words, failed. Investigation later showed that ice had blocked the fuel lines—the icing theory was correct—and Boeing instituted a mechanical change to keep it from happening again. But in the moment, the loss of one engine in this way, potentially two, over the mountains of Montana could have been catastrophic.
The pilot and copilot knew what to do, though. They got out their checklist and followed the lessons it offered. Because they did, the engine recovered, and 247 people were saved. It went so smoothly, the passengers didn’t even notice.
This, it seemed to me, was something to hope for in surgery.
7. THE TEST
Back in Boston, I set my research team to work making our fledgling surgery checklist more usable. We tried to follow the lessons from aviation. We made it clearer. We made it speedier. We adopted mainly a