The Checklist Manifesto_ How to Get Things Right - Atul Gawande [76]
9. THE SAVE
In the spring of 2007, as soon as our surgery checklist began taking form, I began using it in my own operations. I did so not because I thought it was needed but because I wanted to make sure it was really usable. Also, I did not want to be a hypocrite. We were about to trot this thing out in eight cities around the world. I had better be using it myself. But in my heart of hearts—if you strapped me down and threatened to take out my appendix without anesthesia unless I told the truth—did I think the checklist would make much of a difference in my cases? No. In my cases? Please.
To my chagrin, however, I have yet to get through a week in surgery without the checklist’s leading us to catch something we would have missed. Take last week, as I write this, for instance. We had three catches in five cases.
I had a patient who hadn’t gotten the antibiotic she should have received before the incision, which is one of our most common catches. The anesthesia team had gotten distracted by the usual vicissitudes. They had trouble finding a good vein for an IV, and one of the monitors was being twitchy. Then the nurse called a time-out for the team to run the Before Incision check.
“Has the antibiotic been given within the last sixty minutes?” I asked, reading my lines off a wall poster.
“Oh, right, um, yes, it will be,” the anesthesia resident replied. We waited a quiet minute for the medication to flow in before the scrub tech handed over the knife.
I had another patient who specifically didn’t want the antibiotic. Antibiotics give her intestinal upset and yeast infections, she said. She understood the benefits, but the risk of a bacterial wound infection in her particular operation was low—about 1 percent—and she was willing to take her chances. Yet giving an antibiotic was so automatic (when we weren’t distracted from it) that we twice nearly infused it into her, despite her objections. The first time was before she went to sleep and she caught the error herself. The second time was after and the checklist caught it. As we went around the room at the pause before the incision, making sure no one had any concerns, the nurse reminded everyone not to give the antibiotic. The anesthesia attending reacted with surprise. She hadn’t been there for the earlier conversation and was about to drip it in.
The third catch involved a woman in her sixties for whom I was doing a neck operation to remove half of her thyroid because of potential cancer. She’d had her share of medical problems and required a purseful of medications to keep them under control. She’d also been a longtime heavy smoker but had quit a few years before. There seemed to be no significant lingering effects. She could climb two flights of stairs without shortness of breath or chest pain. She looked generally well. Her lungs sounded clear and without wheezes under my stethoscope. The records showed no pulmonary diagnoses. But when she met the anesthesiologist before surgery, she remembered that she’d had trouble breathing after two previous operations and had required oxygen at home for several weeks. In one instance, she’d required a stay in intensive care.
This was a serious concern. The anesthesiologist knew about it, but I didn’t—not until we ran the checklist. When the moment came to raise concerns, the anesthesiologist asked why I wasn’t planning to watch her longer than the usual few hours after day surgery, given her previous respiratory problems.
“What respiratory problems?” I said. The full story came out from there. We made arrangements to keep the patient in the hospital for observation. Moreover, we made plans to give her inhalers during surgery and afterward to prevent breathing problems. They worked beautifully. She never needed extra oxygen at all.
No matter how routine an operation is, the patients never seem to be. But with the checklist in place, we have caught unrecognized drug allergies, equipment problems, confusion about medications, mistakes on labels for biopsy specimens going to pathology. (“No, that one is from the