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By Root 813 0

’s power. In about 20 percent of the operations, after all, a researcher had been physically present in the operating room collecting information. Maybe the observer’s presence was what had improved care. The research team pointed out, however, that the observers had been in the operating rooms from the very beginning of the project, and the results had not leaped upward until the checklist was introduced. Moreover, we’d tracked which operations had an observer and which ones hadn’t. And when Alex rechecked the data, the results proved no different—the improvements were equally dramatic for observed and unobserved operations.

Okay, maybe the checklist made a difference in some places, but perhaps only in the poor sites. No, that didn’t turn out to be the case either. The baseline rate of surgical complications was indeed lower in the four hospitals in high-income countries, but introducing the checklist had produced a one-third decrease in major complications for the patients in those hospitals, as well—also a highly significant reduction.

The team took me through the results for each of the eight hospitals, one by one. In every site, introduction of the checklist had been accompanied by a substantial reduction in complications. In seven out of eight, it was a double-digit percentage drop.

This thing was real.

In January 2009, the New England Journal of Medicine published our study as a rapid-release article. Even before then, word began to leak out as we distributed the findings to our pilot sites. Hospitals in Washington State learned of Seattle’s results and began trying the checklist themselves. Pretty soon they’d formed a coalition with the state’s insurers, Boeing, and the governor to systematically introduce the checklist across the state and track detailed data. In Great Britain, Lord Darzi, the chairman of surgery at St. Mary’s Hospital, had meanwhile been made a minister of health. When he and the country’s top designate to WHO, Sir Liam Donaldson (who had also pushed for the surgery project in the first place), saw the study results, they launched a campaign to implement the checklist nationwide.

The reaction of surgeons was more mixed. Even if using the checklist didn’t take the time many feared—indeed, in several hospitals teams reported that it saved them time—some objected that the study had not clearly established how the checklist was producing such dramatic results. This was true. In our eight hospitals, we saw improvements in administering antibiotics to reduce infections, in use of oxygen monitoring during operations, in making sure teams had the right patient and right procedure before making an incision. But these particular improvements could not explain why unrelated complications like bleeding fell, for example. We surmised that improved communication was the key. Spot surveys of random staff members coming out of surgery after the checklist was in effect did indeed report a significant increase in the level of communication. There was also a notable correlation between teamwork scores and results for patients—the greater the improvement in teamwork, the greater the drop in complications.

Perhaps the most revealing information, however, was simply what the staff told us. More than 250 staff members—surgeons, anesthesiologists, nurses, and others—filled out an anonymous survey after three months of using the checklist. In the beginning, most had been skeptical. But by the end, 80 percent reported that the checklist was easy to use, did not take a long time to complete, and had improved the safety of care. And 78 percent actually observed the checklist to have prevented an error in the operating room.

Nonetheless, some skepticism persisted. After all, 20 percent did not find it easy to use, thought it took too long, and felt it had not improved the safety of care.

Then we asked the staff one more question. “If you were having an operation,” we asked, “would you want the checklist to be used?”

A full 93 percent said yes.

8. THE HERO IN THE AGE OF CHECKLISTS

We have an opportunity