Book Notes: Checklists a matter of life or death, says 'Checklist Manifesto' author

"The Checklist Manifesto: How to Get Things Right" By Atul Gawande. Metropolitan Books, New York, 2009. 209 pages. $24.50.

In the face of complex surgery, perhaps the removal of a dangerous tumor in an adrenal gland, an operating room safety checklist can seem like an idiotic distraction to the highly trained, ultra-specialized surgeon.

Checklists, writes Boston surgeon and author Atul Gawande in his book “The Checklist Manifesto: How to Get Things Right,” are considered by many to be beneath us. In fact, checklists do not resonate with human behavior. We are an inspired lot, motivated by creative juices and reinforced by social values that celebrate heroic individualism. We are cowboys. Do not fence us in with silly lists — busy work. We are doctors. We are venture capitalists. We know best.

Yet Gawande proves, without a doubt, that checklists — cognitive safety nets — save lives, millions of dollars and untold heartache, whether the task is flying an airplane, building a skyscraper or operating on an adrenal gland.

People die every day in hospitals because of preventable errors. Gawande worked with eight hospitals around the world, at the request of the World Health Organization, to find ways to reduce operating room deaths. A significant portion of the care is so unsafe as to be a public danger, they told Gawande. In 2003, surgeons performed 230 million operations around the world, with complication rates ranging from 3 to 17 percent. Resulting from those complications were 1 million deaths, close to the number of deaths due to malaria.

It is dire in the United States, as well. Three hundred thousand Americans get infections after surgery, and 8,000 die annually. Other major surgical complications are bleeding, unsafe anesthesia and the unexpected. Yet half of the post-surgical complications are preventable. Another way to look at it is that you will have seven operations in your lifetime. Cross your fingers and hope for a checklist. Why? Fifty million operations occur yearly here, and there are 150,000 post-surgical deaths — three times that of road traffic fatalities. “What do you do,” asks Gawande, “when expertise is not enough?”

Hospitals from Seattle to Tanzania participated in the WHO study. Observers recorded data for before and after adopting the checklist. The results stunned everyone. In the three months that the OR staffs used the checklists, the major complications dropped by 36 percent. Deaths fell by 47 percent. Infections fell by almost half. The checklist is made up of 19 brief, unambiguous checks that can be called out in two minutes. Checks are as simple as verifying that the correct patient is on the table.

Captain Chesley Sullenberger and his co-pilot Jeffrey Skiles used checklists when they landed their Airbus on the Hudson. Builders of skyscrapers use checklists. The savviest of investors use checklists. Even top chefs use checklists. Success translates as lives saved and money earned.

Perhaps because he’s a doctor or maybe because he has compassion for those most wholly at the mercy of their human fallibilities, Gawande is not judgmental of his peers who refuse the list in their ORs. Forcing the list defeats the purpose. The list is just the first step in a radical shift from autonomous leader (surgeon) to team wisdom. When using the list, nurses and doctors introduce themselves. Those introductions trigger greater participation in problem solving. Talk activates teamwork. In a complex environment like an operating room, with many experts around the table, it is no longer feasible for one person to know it all and call the shots.

Resistant himself to using a checklist, Gawande became a convert when he made a tear in the main vessel returning blood to the heart while removing a tumor from an adrenal gland. In 60 seconds almost all of his patient’s blood emptied into his abdomen. Earlier, when calling the checklist it was discovered that the blood ordered for the surgery had not been readied. They requested the blood from the blood bank and then began the surgery. Freed of the procedural tasks, such as requesting blood in a moment of crisis, Gawande was able to take full advantage of his skills and expertise and devote his entire attention to saving the man. Lists buttress skills, he says. And he should know.

Rae Francoeur can be reached at rae.francoeur@verizon.net. Her book “Free Fall: A Late in Life Love Affair” comes out in April. See her blog at freefallrae.blogspot.com.