Back in June of last year, I posted a blog entry on a WHO study of 8 hospitals that implemented checklists in hospitals:
(http://www.taproot.com/content/2009/01/15/surgery-checklist-reduces-surgery-deaths/)

One of the researchers on this study, Dr. Atul Gawande, was interviewed on National Public Radio this morning (link here).  He went into even more detail and and provided further insight on this study.  He discussed how complicated and intricate the medical profession has become, and therefore instituted the use of checklists in the operating room in 8 hospitals.  He had some amazing (but not unexpected) findings:

“We get better results,” he says. “Massively better results.

“We caught basic mistakes and some of that stupid stuff,” Gawande reports. But the study returned some surprising results: “We also found that good teamwork required certain things that we missed very frequently.”

Like making sure everyone in the operating room knows each other by name. When introductions were made before a surgery, Gawande says, the average number of complications and deaths dipped by 35 percent.

How did the surgeons respond?

…when his team surveyed the doctors who used the checklist, “There was about 80 percent who thought that this was something they wanted to continue to use. But 20 percent remained strongly against it. They said, ‘This is a waste of my time, I don’t think it makes any difference.’ And then we asked them, ‘If you were to have an operation, would you want the checklist?’ 94 percent wanted the checklist.”

Checklists are a way of life in many critical, complex industries.  The airline, nuclear, and pharmaceutical industries all use checklists to some extent, but many in the medical community are still resistant.  We have even seen a reluctance to perform a root cause analysis for sentinel events.  Many people feel that, if they are using a checklist, they are perceived as not being an expert at their job.  And yet, Dr. Gawande had some amazing statistics concerning the sheer volume of information presented to physicians:

     – The average physician evaluates 250 primary diseases and conditions each year
     – These same patients have an additional 900 additional medical problems
     – The doctors prescribed over 300 different medications, 100 lab tests, and performed 40 different types of office procedures
     – In an ICU, the average patient requires 178 individual actions per day (administering drugs, suctioning lungs, etc)
     – Out of those 178 actions, 2 per day (~1%) were performed incorrectly
 
Sometimes, memory is just not enough.  When a sentinel event occurs, perform a TapRooT® analysis.  See how many times “no procedure” and “no standard turnover process” show up as root causes.