The Checklist Manifesto_ How to Get Things Right - Atul Gawande [62]
We began to hear some encouraging stories, however. In London, during a knee replacement by an orthopedic surgeon who was one of our toughest critics, the checklist brought the team to recognize, before incision and the point of no return, that the knee prosthesis on hand was the wrong size for the patient—and that the right size was not available in the hospital. The surgeon became an instant checklist proponent.
In India, we learned, the checklist led the surgery department to recognize a fundamental flaw in its system of care. Usual procedure was to infuse the presurgery antibiotic into patients in the preoperative waiting area before wheeling them in. But the checklist brought the clinicians to realize that frequent delays in the operating schedule meant the antibiotic had usually worn off hours before incision. So the hospital staff shifted their routine in line with the checklist and waited to give the antibiotic until patients were in the operating room.
In Seattle, a friend who had joined the surgical staff at the University of Washington Medical Center told me how easily the checklist had fit into her operating room’s routine. But was it helping them catch errors, I asked?
“No question,” she said. They’d caught problems with antibiotics, equipment, overlooked medical issues. But more than that, she thought going through the checklist helped the staff respond better when they ran into trouble later—like bleeding or technical difficulties during the operation. “We just work better together as a team,” she said.
The stories gave me hope.
In October 2008, the results came in. I had two research fellows, both of them residents in general surgery, working on the project with me. Alex Haynes had taken more than a year away from surgical training to run the eight-city pilot study and compile the data. Tom Weiser had spent two years managing development of the WHO checklist program, and he’d been in charge of double-checking the numbers. A retired cardiac surgeon, William Berry, was the triple check on everything they did. Late one afternoon, they all came in to see me.
“You’ve got to see this,” Alex said.
He laid a sheaf of statistical printouts in front of me and walked me through the tables. The final results showed that the rate of major complications for surgical patients in all eight hospitals fell by 36 percent after introduction of the checklist. Deaths fell 47 percent. The results had far outstripped what we’d dared to hope for, and all were statistically highly significant. Infections fell by almost half. The number of patients having to return to the operating room after their original operations because of bleeding or other technical problems fell by one-fourth. Overall, in this group of nearly 4,000 patients, 435 would have been expected to develop serious complications based on our earlier observation data. But instead just 277 did. Using the checklist had spared more than 150 people from harm—and 27 of them from death.
You might think that I’d have danced a jig on my desk, that I’d have gone running through the operating room hallways yelling, “It worked! It worked!” But this is not what I did. Instead, I became very, very nervous. I started poking through the pile of data looking for mistakes, for problems, for anything that might upend the results.
Suppose, I said, this improvement wasn’t due to the checklist. Maybe, just by happenstance, the teams had done fewer emergency cases and other risky operations in the second half of the study, and that’s why their results looked better. Alex went back and ran the numbers again. Nope, it turned out. The teams had actually done slightly more emergency cases in the checklist period than before. And the mix of types of operations—obstetric, thoracic, orthopedic, abdominal—was unchanged.
Suppose this was just a Hawthorne effect, that is to say, a byproduct of being observed in a study rather than proof of the checklist