The Checklist Manifesto_ How to Get Things Right - Atul Gawande [56]
But compared with the big global killers in surgery, such as infection, bleeding, and unsafe anesthesia, fire is exceedingly rare. Of the tens of millions of operations per year in the United States, it appears only about a hundred involve a surgical fire and vanishingly few of those a fatality. By comparison, some 300,000 operations result in a surgical site infection, and more than eight thousand deaths are associated with these infections. We have done far better at preventing fires than infections. Since the checks required to entirely eliminate fires would make the list substantially longer, these were dropped as well.
There was nothing particularly scientific or even consistent about the decision-making process. Operating on the wrong patient or the wrong side of the body is exceedingly rare too. But the checks to prevent such errors are relatively quick and already accepted in several countries, including the United States. Such mistakes also get a lot of attention. So those checks stayed in.
In contrast, our checks to prevent communication breakdowns tackled a broad and widely recognized source of failure. But our approach—having people formally introduce themselves and briefly discuss critical aspects of a given case—was far from proven effective. Improving teamwork was so fundamental to making a difference, however, that we were willing to leave these measures in and give them a try.
After our London meeting, we did more small-scale testing—just one case at a time. We had a team in London try the draft checklist and give us suggestions, then a team in Hong Kong. With each successive round, the checklist got better. After a certain point, it seemed we had done all we could. We had a checklist we were ready to circulate.
The final WHO safe surgery checklist spelled out nineteen checks in all. Before anesthesia, there are seven checks. The team members confirm that the patient (or the patient’s proxy) has personally verified his or her identity and also given consent for the procedure. They make sure that the surgical site is marked and that the pulse oximeter—which monitors oxygen levels—is on the patient and working. They check the patient’s medication allergies. They review the risk of airway problems—the most dangerous aspect of general anesthesia—and that appropriate equipment and assistance for them are available. And lastly, if there is a possibility of losing more than half a liter of blood (or the equivalent for a child), they verify that necessary intravenous lines, blood, and fluids are ready.
After anesthesia, but before incision, come seven more checks. The team members make sure they’ve been introduced by name and role. They confirm that everyone has the correct patient and procedure (including which side of the body—left versus right) in mind. They confirm that antibiotics were either given on time or were unnecessary. They check that any radiology images needed for the operation are displayed. And to make sure everyone is briefed as a team, they discuss the critical aspects of the case: the surgeon reviews how long the operation will take, the amount of blood loss the team should prepare for, and anything else people should be aware of; the anesthesia staff review their anesthetic plans and concerns; and the nursing staff review equipment availability, sterility, and their patient concerns.
Finally, at the end of the operation, before the team wheels the patient from the room, come five final checks. The circulating nurse verbally