The Checklist Manifesto_ How to Get Things Right - Atul Gawande [55]
Next, we tested it in a simulator, otherwise known as the conference room on my hallway at the school of public health where I do research. We had an assistant lie on a table. She was our patient. We assigned different people to play the part of the surgeon, the surgical assistant, the nurses (one scrubbed-in and one circulating), and the anesthesiologist. But we hit problems just trying to get started.
Who, for example, was supposed to bring things to a halt and kick off the checklist? We’d been vague about that, but it proved no small decision. Getting everyone’s attention in an operation requires a degree of assertiveness—a level of control—that only the surgeon routinely has. Perhaps, I suggested, the surgeon should get things started. I got booed for this idea. In aviation, there is a reason the “pilot not flying” starts the checklist, someone pointed out. The “pilot flying” can be distracted by flight tasks and liable to skip a checklist. Moreover, dispersing the responsibility sends the message that everyone—not just the captain—is responsible for the overall well-being of the flight and should have the power to question the process. If a surgery checklist was to make a difference, my colleagues argued, it needed to do likewise—to spread responsibility and the power to question. So we had the circulating nurse call the start.
Must nurses make written check marks? No, we decided, they didn’t have to. This wasn’t a record-keeping procedure. We were aiming for a team conversation to ensure that everyone had reviewed what was needed for the case to go as well as possible.
Every line of the checklist needed tweaking. We timed each successive version by a clock on the wall. We wanted the checks at each of the three pause points—before anesthesia, before incision, and before leaving the OR—to take no more than about sixty seconds, and we weren’t there yet. If we wanted acceptance in the high-pressure environment of operating rooms, the checklist had to be swift to use. We would have to cut some lines, we realized—the non–killer items.
This proved the most difficult part of the exercise. An inherent tension exists between brevity and effectiveness. Cut too much and you won’t have enough checks to improve care. Leave too much in and the list becomes too long to use. Furthermore, an item critical to one expert might not be critical to another. In the spring of 2007, we reconvened our WHO group of international experts in London to consider these questions. Not surprisingly, the most intense disagreements flared over what should stay in and what should come out.
European and American studies had discovered, for example, that in long operations teams could substantially reduce patients’ risks of developing deep venous thrombosis—blood clots in their legs that can travel to their lungs with fatal consequences—by injecting a low dose of a blood thinner, such as heparin, or slipping compression stockings onto their legs. But researchers in China and India dispute the necessity, as they have reported far lower rates of blood clots in their populations than in the West and almost no deaths. Moreover, for poor-and middle-income countries, the remedies—stockings or heparin—aren’t cheap. And even a slight mistake by inexperienced practitioners administering the blood thinner could cause a dangerous overdose. The item was dropped.
We also discussed operating room fires, a notorious problem. Surgical teams rely on high-voltage electrical equipment, cautery devices that occasionally arc while in use, and supplies of high-concentration oxygen—all sometimes in close proximity. As a result, most facilities in the world have experienced a surgical fire. These fires are terrifying. Pure oxygen can make almost anything instantly flammable—the surgical drapes over a patient, for instance, and even