ALSO BY ATUL GAWANDE BETTER: A SURGEON'S NOTES ON . 4 THE CHECKLIST MANIFESTO He told me about another patient, who was undergoing an. PDF | On Oct 1, , David Newbold and others published Book review: The The Checklist Manifesto. How. to get things right. Atul. Gawande, Proﬁle Books. The Checklist Manifesto PDF Summary by Atul Gawande is literally a guide for How to Get Things Right and done efficiently. Stop with the.
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ALSO BY ATUL GAWANDE. BETTER: A SURGEON'S NOTES ON PERFORMANCE. COMPLICATIONS: A SURGEON'S NOTES ON AN IMPERFECT SCIENCE. THE CHECKLIST. MANIFESTO. How to Get Things Right. ATUL GAWANDE. ATUL GAWANDEis a general surgeon in Boston, a staff writer for The New Yorker. Editorial Reviews. soundofheaven.info Review. Amazon Best Books of the Month, December Available; Part of the Atul Gawande (4 Book Bundle). Kindle e -.
He got into an altercation. Download a Mountain of Knowledge For those of you who want to learn something new daily, 12min App takes you on a personal development journey with the key takeaways from the greatest bestsellers. Mistakes are still made. John paused here in telling the story and asked me to suppose I was in his situation. Each percentage point, after all, represented millions left disabled or dead. And there is such a strategy — though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully develop- ing ever more advanced skills and technologies. It employed at the time eight hundred physicians, seven hundred nurses, and two thousand other med- ical personnel to care for a population with the lowest median income of any city in the country More than a quarter of a mil- lion residents were uninsured; , were on state assistance.
Lives of patients who a few years ago would have faced certain death are now saved every day. For all this advancement, however, a surprising number of patients are still dying because of human error. The World Health Organization estimates there are more than 13, different diseases, syndromes, and injuries. For almost all of them, science provides a means of helping — either by curing disease or by reducing the evil and misery involved. The problem is that for each situation, treatment can change.
Doctors have about 6, remedies and about 4, medical and surgical procedures from which to choose. This number is too high for anyone, even for someone trained. Specialty areas were further divided and focused into subspecialties. For example, there were once anesthesiologists in charge of pain control and patient stability during operations.
Today there are pediatric anesthesiologists, cardiac anesthesiologists, obstetric anesthesiologists and many others. In the early 20th century, you could receive a license to practice medicine if you had a high school diploma and a one-year medical degree.
By the end of the 20th century, to become a doctor, you needed a college degree, a four-year medical degree, and an additional residency training in one area of practice — such as pediatrics, surgery, neurology, among others. Nowadays, even this level of preparation may be inadequate. Most doctors also do other programs that involve additional training of one or two years.
Doctors do not begin to practice independently until they are in their mid-thirties or more. Many industries nowadays have increased in complexity similar to the medical sector. Much of what designers, financial managers, firefighters, police officers and doctors do now is too complex to be solved only with memory. The solution is to integrate the more systematic use of checklists in daily operations. In a complex environment, experts have to deal with two major difficulties: Checklists protect against these two scenarios.
By making the minimum steps necessary to be explicit and verified, you encourage discipline that can increase your performance levels. They ensure professionals apply their knowledge and expertise in the right way. Most assume that checklists only work in repetitive and routine situations, but this is not true. At the same time, the levees that protected the city ruptured.
He witnessed several residents trapped on rooftops and many bodies floating in the water. The only problem with that was that the top FEMA officials did not use e-mail, so they did not know about the emergency until they saw TV images the next day.
For days, the federal, state and local governments debated who should react, while the situation continued to deteriorate. In contrast, Wal-Mart had stores closed in the New Orleans region. CEO Lee Scott told everyone: Many of you will need to make decisions above the level. Make the best decision you can with the information that is available, and most importantly do the right thing. Acting alone, Wal-Mart managers began distributing diapers, water, and ice to residents affected by the flood.
Wal-Mart organized an emergency response team, which also included a member of the Red Cross and within two days they took trucks with food, water, and emergency equipment to New Orleans. Officials set up mobile pharmacies that provided free medicines. The moral of this story is not the idea that the private sector is better than the public sector in dealing with complex situations. Many businesses in New Orleans were unprepared to deal with the situation, and the local police and firefighters did an incredible job serving the communities.
The real lesson was that, under highly complex situations, a centralized decision chain does not work very well. Instead, you have better results by planning what needs to happen in a simple checklist, and then giving individuals the freedom to act and adapt, while following specified guidelines.
Lists work very well in complex situations because they strike a balance between different virtues.
The Checklist Manifesto Lists help us achieve a balance by providing a set of checks to ensure that essential and critical things have are not ignored while also ensuring that people work to achieve shared goals. Another good feature about checklists is that they can be used to coordinate the activities of different teams quickly and concisely.
Checklists may seem like a simple concept in a complex world, but they obviously work. Good lists take the obvious routine tasks out of your mind so that you can focus on the difficult things.
They may work in all industries — and will work even better in the future, with increasing complexity of things. In , Peter Pronovost, an intensive care specialist at John Hopkins Hospital, was frustrated with the incidence of central line infection in intensive care.
He created a simple checklist of the steps that needed to be taken to prevent infection. As simple as the steps look, the ICU nurses noted that doctors were often in such a hurry that they ignored a step or two. With this information, Pronovost persuaded the hospital administration to allow nurses to prevent doctors from putting central lines if they ignored a checklist step.
Still, as he began touring the country to show his checklists to doctors, nurses, and administrators, few showed an interest in adopting the idea. Doctors were offended by the idea of using a list at work, and the idea of filling in another document seemed problematic to them.
They agreed to give hospitals a small financial bonus to participate in the program. Each hospital had a project manager and a senior executive to run the program. They also persuaded Arrow International, one of the largest manufacturers of centerlines, to produce a new centerline kit with surgery drapes and antiseptic soap. For experts using checklists, their efficiency can be seen in commercial aviation.
The current generation of commercial pilots carries pocket guides that have numerous checklists. On January 17, , while a British Airways flight was approaching London after 11 hours of travel, both engines failed at meters high and about 3 kilometers away from the airport.
As the plane landed, the wheels collapsed and the main landing gear was ripped out and into the passenger compartment. This malfunction caused more than liters of gas to flow, but fortunately, there was no explosion, and the passengers and crew were able to land safely. Investigators scanned the entire plane to try to determine what caused the crash.
It is a checklist. It was, in the dry prose of a medical journal article, the story of a nightmare. In a small Austrian town in the Alps, a mother and father had been out on a walk in the woods with their three-year- old daughter. The parents lost sight of the girl for a moment and that was all it took. She fell into an icy fishpond. The parents fran- tically jumped in after her.
But she was lost beneath the surface for thirty minutes before they finally found her on the pond bottom. They pulled her to the surface and got her to the shore.
Follow- ing instructions from an emergency response team reached on their cell phone, they began cardiopulmonary resuscitation. She was unresponsive. Her body temperature was just 66 degrees.
Her pupils were dilated and unreactive to light, indicating cessation of brain function.
She was gone. But the emergency technicians continued CPR anyway. A hel- icopter took her to the nearest hospital, where she was wheeled directly into an operating room, a member of the emergency crew straddling her on the gurney, pumping her chest. A surgical team got her onto a heart-lung bypass machine as rapidly as it could. A perfusionist turned the pump on, and as he adjusted the oxy- gen and temperature and flow through the system, the clear tub- ing turned maroon with her blood.
Between the transport time and the time it took to plug the machine into her, she had been lifeless for an hour and a half.
By the two-hour mark, however, her body temperature had risen almost ten degrees, and her heart began to beat. It was her first organ to come back. The team tried to shift her from the bypass machine to a mechanical ventilator, but the pond water and debris had damaged her lungs too severely for the oxygen pumped in through the breathing tube to reach her blood. So they switched her instead to an artificial-lung system known as ECMO — extracorporeal membrane oxygenation.
The ECMO machine now took over. The surgeons removed the heart-lung bypass machine tubing. They repaired the vessels and closed her groin incision. The surgical team moved the girl into intensive care, with her chest still open and covered with sterile plastic foil. Through the day and night, the intensive care unit team worked on suctioning the water and debris from her lungs with a fiberoptic bronchoscope. By the next day, her lungs had recovered sufficiently for the team to switch her from ECMO to a mechanical ventilator, which required taking her back to the operating room to unplug the tubing, repair the holes, and close her chest.
A CT scan showed global brain swelling, which is a sign of diffuse damage, but no actual dead zones. So the team escalated the care one step further.
For more than a week, she lay comatose. Then, slowly, she came back to life. First, her pupils started to react to light. Next, she began to breathe on her own. And, one day, she simply awoke. Two weeks after her accident, she went home. Her right leg and left arm were partially paralyzed. Her speech was thick and slurry. But she underwent extensive outpatient therapy. By age five, she had recovered her faculties completely.
Physical and neurological examinations were normal. She was like any little girl again. Rescuing a drowning vic- tim is nothing like it looks on television shows, where a few chest compressions and some mouth-to-mouth resuscitation always seem to bring someone with waterlogged lungs and a stilled heart coughing and sputtering back to life.
To save this one child, scores of people had to carry out thousands of steps correctly: The degree of difficulty in any one of these steps is substantial. Then you must add the difficulties of orchestrating them in the right sequence, with nothing dropped, leaving some room for improvisation, but not too much. I think we have been fooled about what we can expect from medicine — fooled, one could say, by penicillin.
So why not a similar cure-all for the different kinds of cancer? And why not something equally simple to melt away skin burns or to reverse cardiovascular disease and strokes? Medicine didn't turn out this way, though. After a century of incredible discovery most diseases have proved to be far more particular and difficult to treat. This is true even for the infections doctors once treated with penicillin: Infec- tions today require highly individualized treatment, sometimes with multiple therapies, based on a given strain's pattern of anti- biotic susceptibility, the condition of the patient, and which organ systems are affected.
The model of medicine in the mod- ern age seems less and less like penicillin and more and more like what was required for the girl who nearly drowned. Medicine has become the art of managing extreme complexity — and a test of whether such complexity can, in fact, be humanly mastered. The ninth edition of the World Health Organization's inter- national classification of diseases has grown to distinguish more than thirteen thousand different diseases, syndromes, and types of injury — more than thirteen thousand different ways, in other words, that the body can fail.
And, for nearly all of them, science has given us things we can do to help. If we cannot cure the dis- ease, then we can usually reduce the harm and misery it causes. But for each condition the steps are different and they are almost never simple.
Clinicians now have at their disposal some six thou- sand drugs and four thousand medical and surgical procedures, each with different requirements, risks, and considerations, ft is a lot to get right. Founded in , and now called Harvard Vanguard, it aimed to provide people with the full range of out- patient medical services they might need over the course of their lives.
To keep up with the explosive growth in medical capa- bilities, the clinic has had to build more than twenty facilities and employ some six hundred doctors and a thousand other health professionals covering fifty-nine specialties, many of which did not exist when the clinic first opened. But even divvied up, the work can become over- whelming. In the course of one day on general surgery call at the hospital, for instance, the labor floor asked me to see a twenty- five -year-old woman with mounting right lower abdominal pain, fever, and nausea, which raised concern about appendicitis, but she was pregnant, so getting a CT scan to rule out the possibility posed a risk to the fetus.
A gynecological oncologist paged me to the operating room about a woman with an ovarian mass that upon removal appeared to be a metastasis from pancreatic can- cer; my colleague wanted me to examine her pancreas and decide whether to biopsy it. Our internal med- icine service called me to see a sixty-one-year-old man with emphysema so severe he had been refused hip surgery because of insufficient lung reserves; now he had a severe colon infection — an acute diverticulitis — that had worsened despite three days of antibiotics, and surgery seemed his only option.
Another service asked for help with a fifty -two-year-old man with diabetes, coronary artery disease, high blood pressure, chronic kidney failure, severe obesity, a stroke, and now a strangulating groin hernia. And an internist called about a young, otherwise healthy woman with a possible rectal abscess to be lanced.
But extreme complexity is the rule for almost everyone. The answer that came back flabbergasted me. Over the course of a year of office practice — which, by definition, excludes the patients seen in the hospital — physicians each evaluated an average of different primary diseases and conditions. Their patients had more than nine hun- dred other active medical problems that had to be taken into account.
The doctors each prescribed some three hundred med- ications, ordered more than a hundred different types of labora- tory tests, and performed an average of forty different kinds of office procedures — from vaccinations to setting fractures. But, even when you do have the time, you commonly find that the particular diseases your patients have do not actually exist in the computer system.
The software used in most American electronic records has not managed to include all the diseases that have been discovered and distinguished from one another in recent years. I once saw a patient with a ganglioneuroblastoma a rare type of tumor of the adrenal gland and another with a nightmarish genetic condition called Li-Fraumeni syndrome, which causes inheritors to develop cancers in organs all over their bodies.
Neither disease had yet made it into the pull-down menus. The complexity is increasing so fast that even the computers cannot keep up. It is also the execution — the practical matter of what knowledge requires clinicians to do. The hospital is where you see just how formidable the task can be.
A prime example is the place the girl who nearly drowned spent most of her recovery — the intensive care unit. It's an opaque term, intensive care. Specialists in the field prefer to call what they do critical care, but that still doesn't exactly clar- ify matters. The nonmedical term life support gets us closer. The damage that the human body can survive these days is as awe- some as it is horrible: These maladies were once uniformly fatal.
Now survival is com- monplace, and a substantial part of the credit goes to the abilities intensive care units have developed to take artificial control of failing bodies.
Typically, this requires a panoply of technology — a mechanical ventilator and perhaps a tracheostomy tube if the lungs have failed, an aortic balloon pump if the heart has given out, a dialysis machine if the kidneys don't work. If you are uncon- scious and can't eat, silicone tubing can be surgically inserted into your stomach or intestines for formula feeding.
If your intestines are too damaged, solutions of amino acids, fatty acids, and glu- cose can be infused directly into your bloodstream. On any given day in the United States alone, some ninety thousand people are admitted to intensive care.
Over a year, an estimated five million Americans will be, and over a normal life- time nearly all of us will come to know the glassed bay of an ICU from the inside. Wide swaths of medicine now depend on the life support systems that ICUs provide: Critical care has become an increasingly large portion of what hospitals do.
Fifty years ago, ICUs barely existed. Now, to take a recent random day in my hospital, of our almost patients are in intensive care. The average stay of an ICU patient is four days, and the survival rate is 86 percent. Going into an ICU, being put on a mechanical ventilator, having tubes and wires run into and out of you, is not a sentence of death.
But the days will be the most precarious of your life. Fifteen years ago, Israeli scientists published a study in which engineers observed patient care in ICUs for twenty-four-hour 24 THE checklist manifesto stretches. They found that the average patient required indi- vidual actions per day, ranging from administering a drug to suc- tioning the lungs, and every one of them posed risks.
Remarkably, the nurses and doctors were observed to make an error in just 1 percent of these actions — but that still amounted to an average of two errors a day with every patient. Intensive care succeeds only when we hold the odds of doing harm low enough for the odds of doing good to prevail.
This is hard. There are dangers simply in lying unconscious in bed for a few days. Muscles atrophy. Bones lose mass. Pressure ulcers form. Veins begin to clot. Add a ventilator, dialysis, and the care of open wounds, and the difficul- ties only accumulate. The story of one of my patients makes the point. Anthony DeFilippo was a forty-eight-year-old limousine driver from Everett, Massachusetts, who started to hemorrhage at a community hospital during surgery for a hernia and gallstones.
I accepted him for transfer in order to stabilize him and figure out what to do. When he arrived in our ICU, at 1: He was delirious from fever, shock, and low oxygen levels.
We turned up his oxygen flow, put his wrists in cloth restraints, and tried to reason with him. He eventually tired out and let us draw blood and give him anti- biotics. The laboratory results came back showing liver failure and a steeply elevated white blood cell count, indicating infection.
It soon became evident from his empty urine bag that his kidneys had failed, too. In the next few hours, his blood pressure fell, his breathing worsened, and he drifted from agitation to near uncon- sciousness. Each of his organ systems, including his brain, was shutting down. I called his sister, his next of kin, and told her the situation. So we did. We gave him a syringeful of anesthetic, and a resi- dent slid a breathing tube into his throat. Next, she put in a central line — a twelve -inch catheter pushed into the jugular vein in his left neck.
After she sewed that in place, and an X-ray showed its tip floating just where it was supposed to — inside his vena cava at the entrance to his heart — she put a third, slightly thicker line, for dialysis, through his right upper chest and into the subclavian vein, deep under the collarbone. We dialed the ventilator pressures and gas flow up and down, like engineers at a control panel, until we got the blood levels of oxygen and carbon dioxide where we wanted them. The arterial line gave us continuous arterial blood pressure measurements, and we tweaked his medications to get the pres- sures we liked.
We regulated his intravenous fluids according to venous pressure measurements from his jugular line. We plugged his subclavian line into tubing from a dialysis machine, and every few minutes his entire blood volume washed through this artifi- cial kidney and back into his body; a little adjustment here and there, and we could alter the levels of potassium and bicarbonate and salt, as well.
He was, we liked to imagine, a simple machine in our hands. But he wasn't, of course. It was as if we had gained a steer- ing wheel and a few gauges and controls, but on a runaway wheeler hurtling down a mountain. He was on near-maximal ventilator support.
His temperature climbed to degrees. A single misstep could easily erase those slender chances. For ten days, though, we made progress. He had become too sick to survive an operation to repair the leak. They found so much that they had to place three drains — one inside the duct and two around it. But, as the bile drained out, his fevers subsided. His need for oxygen and fluids diminished, and his blood pressure returned to normal.
He was beginning to mend. Then, on the eleventh day, just as we were getting ready to take him off the ventilator, he again developed high, spiking fevers, his blood pressure sank, and his blood-oxygen levels plummeted again. His skin became clammy. He got shaking chills. He seemed to have developed an infection, but our X-rays and CT scans failed to turn up a source.
Even after we put him on four antibiotics, he continued to spike fevers. During one fever, his heart went into fibrillation. A Code Blue was called. A dozen nurses and doctors raced to his bedside, slapped electric paddles onto his chest, and shocked him.
His heart responded and went back into rhythm, ft took two more days for us to figure out what had gone wrong. We considered the possibility that one of his lines had become infected, so we put in new lines and sent the old ones to the lab for culturing. Forty-eight hours later, the results returned. All the lines were infected. Then they all began spilling bacteria into him, producing the fevers and steep decline.
This is the reality of intensive care: ICUs put five million lines into patients each year, and national statistics show that after ten days 4 percent of those lines become infected.
Line infections occur in eighty thousand people a year in the United States and are fatal between 5 and 28 percent of the time, depending on how sick one is at the start.
Those who survive line infections spend on average a week longer in intensive care. And this is just one of many risks. After ten days with a urinary catheter, 4 per- cent of American ICU patients develop a bladder infection.
After ten days on a ventilator, 6 percent develop bacterial pneumonia, resulting in death 40 to 45 percent of the time. All in all, about half of ICU patients end up experiencing a serious complication, and once that occurs the chances of survival drop sharply.
It was another week before DeFilippo recovered sufficiently from his infections to come off the ventilator and two months before he left the hospital. Weak and debilitated, he lost his lim- ousine business and his home, and he had to move in with his sis- ter.
The tube draining bile still dangled from his abdomen; when he was stronger, I was going to have to do surgery to reconstruct the main bile duct from his liver. But he survived. Most people in his situation do not. He 16 , then, is the fundamental puzzle of modern medical care: So what do you do? That, however, was actually an intensivist as intensive care specialists like to be called. As a general surgeon, I like to think I can handle most clinical situations.
But, as the intricacies involved in intensive care have grown, responsibility has increasingly shifted to super- specialists. In the past decade, training programs focusing on criti- cal care have opened in most major American and European cities, and half of American ICUs now rely on superspecialists. Expertise is the mantra of modern medicine.
In the early twentieth century, you needed only a high school diploma and a one-year medical degree to practice medicine. In recent years, though, even this level of preparation has not been enough for the new complexity of medicine. After their residencies, most young doctors today are going on to do fellowships, adding one to three further years of training in, say, laparoscopic surgery, or pediatric metabolic disor- ders, or breast radiology, or critical care.
We live in the era of the superspecialist — of clinicians who have taken the time to practice, practice, practice at one narrow thing until they can do it better than anyone else. There are degrees of complexity, though, and medicine and other fields like it have grown so far beyond the usual kind that avoiding daily mistakes is proving impossible even for our most superspecialized.
There is perhaps no field that has taken specialization further than surgery. Think of the operating room as a particularly aggressive intensive care unit. We have anesthesiologists just to handle pain control and patient stability, and even they have divided into subcategories. There are pediatric anesthesiologists, cardiac anesthesiologists, obstetric anesthesiologists, neurosurgi- cal anesthesiologists, and many others.
Then of course there are the surgeons. I am trained as a general surgeon but, except in the most rural places, there is no such thing. The result of the recent decades of ever-refined specialization has been a spectacular improvement in surgical capability and success.
Where deaths were once a double-digit risk of even small operations, and prolonged recovery and disability was the norm, day surgery has become commonplace. We continue to have upwards of , deaths following surgery every year — more than three times the number of road traffic fatalities. Moreover, research has consistently showed that at least half our deaths and major complications are avoidable. The knowledge exists. But however supremely specialized and trained we may have become, steps are still missed.
Mistakes are still made. Medicine, with its dazzling successes but also frequent failures, therefore poses a significant challenge: What do you do when expertise is not enough? What do you do when even the super- specialists fail? The army planned to order at least sixty-five of the aircraft. It was sleek and impressive, with a foot wingspan and four engines jutting out from the wings, rather than the usual two. The plane roared down the tarmac, lifted off smoothly, and climbed sharply to three hundred feet.
Then it stalled, turned on one wing, and crashed in a fiery explosion. Two of the five crew members died, including the pilot, Major Ployer P. An investigation revealed that nothing mechanical had gone wrong. Substantially more complex than previous aircraft, the new plane required the pilot to attend to the four engines, each with its own oil-fuel mix, the retractable landing gear, the wing flaps, electric trim tabs that needed adjustment to maintain stability at different airspeeds, and constant-speed propellers whose pitch had to be regulated with hydraulic controls, among other features.
While doing all this, Hill had forgotten to release a new locking mecha- nism on the elevator and rudder controls. The Boeing model was deemed, as a newspaper put it, "too much airplane for one man to fly. Boeing nearly went bankrupt. Still, the army purchased a few aircraft from Boeing as test planes, and some insiders remained convinced that the aircraft was flyable. So a group of test pilots got together and considered what to do.
What they decided not to do was almost as interesting as what they actually did. They did not require Model pilots to undergo longer training. Instead, they came up with an ingeniously 34 the checklist manifesto simple approach: Its mere exis- tence indicated how far aeronautics had advanced. In the early years of flight, getting an aircraft into the air might have been nerve-racking but it was hardly complex.
Using a checklist for takeoff would no more have occurred to a pilot than to a driver backing a car out of the garage. But flying this new plane was too complicated to be left to the memory of any one person, how- ever expert. The test pilots made their list simple, brief, and to the point — short enough to fit on an index card, with step-by-step checks for takeoff, flight, landing, and taxiing.
It had the kind of stuff that all pilots know to do. They check that the brakes are released, that the instruments are set, that the door and windows are closed, that the elevator controls are unlocked — dumb stuff.
But with the checklist in hand, the pilots went on to fly the Model a total of 1. The army ultimately ordered almost thirteen thousand of the aircraft, which it dubbed the B And, because flying the behemoth was now possible, the army gained a decisive air advantage in the Second World War, enabling its devastating bombing campaign across Nazi Germany. Much of our work today has entered its own B phase. Sub- stantial parts of what software designers, financial managers, fire- fighters, police officers, lawyers, and most certainly clinicians do are now too complex for them to carry out reliably from mem- ory alone.
Multiple fields, in other words, have become too much airplane for one person to fly. Yet it is far from obvious that something as simple as a checklist could be of substantial help. But we believe our jobs are too complicated to reduce to a checklist.
Sick people, for instance, are phenomenally more various than airplanes. A study of forty- one thousand trauma patients in the state of Pennsylvania — just trauma patients — found that they had 1, different injury- related diagnoses in 32, unique combinations.
Mapping out the proper steps for every case is not possible, and physicians have been skeptical that a piece of paper with a bunch of little boxes would improve matters. But we have had glimmers that it might, at least in some cor- ners. What, for instance, are the vital signs that every hospital records if not a kind of checklist? Comprised of four physiologi- cal data points — body temperature, pulse, blood pressure, and respiratory rate — they give health professionals a basic picture of how sick a person is.
Practitioners have had the means to measure vital signs since the early twentieth century, after the mercury thermome- ter became commonplace and the Russian physician Nicolai Korotkoff demonstrated how to use an inflatable sleeve and stethoscope to quantify blood pressure.
But although using the four signs together as a group gauged the condition of patients more accurately than using any of them singly, clinicians did not reliably record them all. The first is the fallibility of human memory and atten- tion, especially when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events.
Faulty memory and distraction are a particular danger in what engineers call all-or-none processes: A further difficulty, just as insidious, is that people can lull themselves into skipping steps even when they remember them. Perhaps the elevator controls on airplanes are usually unlocked and a check is pointless most of the time. Perhaps measuring all four vital signs uncovers a worrisome issue in only one out of fifty patients.
Until one day it is. Checklists seem to provide protection against such failures. They remind us of the minimum necessary steps and make them explicit. They not only offer the possibility of verification but also instill a kind of discipline of higher performance. Which is pre- cisely what happened with vital signs — though it was not doctors who deserved the credit.
The routine recording of the four vital signs did not become the norm in Western hospitals until the s, when nurses embraced the idea. They designed their patient charts and forms to include the signs, essentially creating a checklist for themselves. In most hospitals, nurses have since added a fifth vital sign: And nurses have developed yet further such bedside innovations — for example, medication timing charts and brief written care plans for every patient.
They are nothing that we doctors, with our extra years of training and specialization, would ever need or use. In , though, a critical care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give a doctor checklist a try.
He designed it to tackle just one of their hundreds of potential tasks, the one that nearly killed Anthony DeFilippo: On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting in a central line. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist for something so obvious. Still, Pronovost asked the nurses in his ICU to observe the doctors for a month as they put lines into patients and record how often they carried out each step.
In more than a third of patients, they skipped at least one. The next month, he and his team persuaded the Johns Hop- kins Hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask the doctors each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. The new rule made it clear: For a year afterward, Pronovost and his colleagues monitored what happened.
So they followed patients for fif- teen more months. Only two line infections occurred during the entire period.
One aimed to ensure that nurses observed patients for pain at least once every four hours and provided timely pain medication. The propor- tion of patients not receiving the recommended care dropped from 70 percent to 4 percent, the occurrence of pneumonias fell by a quarter, and twenty-one fewer patients died than in the pre- vious year. The researchers found that simply having the doctors and nurses in the ICU create their own checklists for what they thought should be done each day improved the consistency of care to the point that the average length of patient stay in inten- sive care dropped by half.
These checklists accomplished what checklists elsewhere have done, Pronovost observed. They helped with memory recall and clearly set out the minimum necessary steps in a process. He was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions.
Checklists, he found, established a higher standard of baseline performance. These seem, of course, ridiculously primitive insights. But, really, does it take all that to figure out what anyone who has made a to-do list figured out ages ago? Well, maybe yes. Despite his initial checklist results, takers were slow to come. He traveled around the country showing his checklists to doc- tors, nurses, insurers, employers — anyone who would listen.
He spoke in an average of seven cities a month. But few adopted the idea. There were various reasons. Some physicians were offended by the suggestion that they needed checklists.
How about in the real world — where ICU nurses and doctors are in short supply, pressed for time, overwhelmed with patients, and hardly receptive to the notion of filling out yet another piece of paper? It would be a huge undertaking.
But Pronovost would have a chance to establish whether his check- lists could really work in the wider world. I visited Sinai-Grace Hospital, in inner-city Detroit, a few years after the project was under way, and I saw what Pronovost was up against. It employed at the time eight hundred physicians, seven hundred nurses, and two thousand other med- ical personnel to care for a population with the lowest median income of any city in the country More than a quarter of a mil- lion residents were uninsured; , were on state assistance.
That meant chronic financial problems. Sinai-Grace is not the most cash-strapped hospital in the city — that would be Detroit Receiving Hospital, where more than a fifth of the patients have no means of payment. Sinai-Grace has five ICUs for adult patients and one for infants. Hassan Makki, the director of intensive care, told me what it was like there in , when Pronovost and the hospital association started a series of mailings and conference calls with hospitals to introduce checklists for central lines and ventilator patients.
Meanwhile, the teams faced an even heavier workload because of new rules limiting how long the residents could work at a stretch. Now Pronovost was telling them to find the time to fill out some daily checklists? Tom Piskorowski, one of the ICU physicians, told me his reaction: Take care of the patient.
It had eleven patients. Five patients had cerebral hemorrhaging three were seventy-nine years and older and had been injured falling down stairs; one was a middle-aged man whose skull and left temporal lobe had been damaged by an assault with a blunt weapon; and one was a worker who had become paralyzed from the neck down after falling twenty-five feet off a ladder onto his head.
There was a cancer patient recovering from surgery to remove part of his lung, and a patient who had had surgery to repair a cerebral aneurysm. The doctors and nurses on rounds tried to proceed methodi- cally from one room to the next but were constantly interrupted: It was hard to imagine that they could get their heads far enough above the daily tide of disasters to worry about the minutiae on some checklist.
Yet there they were, I discovered, filling out those pages. Mostly, it was the nurses who kept things in order. Each morn- ing, a senior nurse walked through the unit, clipboard in hand, making sure that every patient on a ventilator had the bed propped at the right angle and had been given the right medi- cines and the right tests. Looking back through the hos- pital files, I found that they had been doing this faithfully for more than three years.
Pronovost had been canny when he started. Instead, he asked them simply to gather data on their own line infection rates. In early , they found, the infection rates for ICU patients in Michigan hospitals were higher than the national average, and in some hos- pitals dramatically so. Sinai-Grace experienced more central line infections than 75 percent of American hospitals. A checklist suddenly seemed an easy and logical thing to try.
In what became known as the Keystone Initiative, each hospi- tal assigned a project manager to roll out the checklist and par- ticipate in twice-monthly conference calls with Pronovost for troubleshooting. The executives were reluctant. They normally lived in meet- ings, worrying about strategy and budgets. In some places, they encountered hostility, but their involve- ment proved crucial.
In the first month, the executives discovered that chlorhexidine soap, shown to reduce line infections, was available in less than a third of the ICUs. This was a problem only an executive could solve. Within weeks, every ICU in Michigan had a supply of the soap. Teams also complained to the hospital officials that, although the checklist required patients be fully covered with a sterile drape when lines were being put in, full- size drapes were often unavailable.
So the officials made sure that drapes were stocked. Then they persuaded Arrow International, 44 the checklist manifesto one of the largest manufacturers of central lines, to produce a new kit that had both the drape and chlorhexidine in it.
The successes have been sustained for sev- eral years now — all because of a stupid little checklist. It is tempting to think this might be an isolated success. Perhaps there is something unusual about the strategy required to pre- vent central line infections. It just prevented infections.
In this particular instance, yes, doctors had some trouble getting the basics right — making sure to wash their hands, put on their ster- ile gloves and gown, and so on — and a checklist proved dramati- cally valuable. But among the myriad tasks clinicians carry out for patients, maybe this is the peculiar case. I started to wonder, though.
Among the many details that intrigued me about the save was the fact that it occurred not at a large cutting-edge academic medical center but at an ordinary community hospital. This one was in Klagenfurt, a small provin- cial Austrian town in the Alps nearest to where the girl had fallen in the pond.
I asked Thalmann how the hospital had managed such a complicated rescue. He told me he had been working in Klagenfurt for six years when the girl came in.
She had not been the first person whom he and his colleagues had tried to revive from cardiac arrest after hypothermia and suffocation. His hospital received between three and five such patients a year, he estimated, mostly avalanche vic- tims, some of them drowning victims, and a few of them people attempting suicide by taking a drug overdose and then wander- ing out into the snowy Alpine forests to fall unconscious.
For a long time, he said, no matter how hard the hospital's medical staff tried, they had no survivors. Most of the victims had been without a pulse and oxygen for too long when they were found. But some, he was convinced, still had a flicker of viability in them, yet he and his colleagues had always failed to sustain it.
He took a close look at the case records. Preparation, he determined, was the chief difficulty. Success required having an array of people and equipment at the ready — trauma surgeons, a cardiac anesthesiologist, a cardiothoracic surgeon, bioengineer- ing support staff, a cardiac perfusionist, operating and critical care nurses, intensivists. Almost routinely, someone or some- thing was missing. He tried the usual surgical approach to remedy this — yelling at everyone to get their act together.
But still they had no saves. They made a checklist. They gave the checklist to the people with the least power in the whole process — the rescue squads and the hospital telephone operator — and walked them through the details. In cases like these, the checklist said, rescue teams were to tell the hospital to prepare for possible cardiac bypass and rewarming. They were to call, when possible, even before they arrived on the scene, as the preparation time could be significant.
The telephone operator would then work down a list of people to notify them to have everything set up and standing by. With the checklist in place, the team had its first success — the rescue of the three-year-old girl. Not long afterward, Thalmann left to take a job at a hospital in Vienna. The team, however, has since had at least two other such rescues, he said.
In one case, a man had been found frozen and pulseless after a suicide attempt. In another, a mother and her sixteen-year-old daughter were in an accident that sent them and their car through a guardrail, over a cliff, and into a mountain river. The mother died on impact; the daughter was trapped as the car rapidly filled with icy water.
She had been in cardiac and respiratory arrest for a prolonged period of time when the rescue team arrived. From that point onward, though, everything moved like clockwork. By the time the rescue team got to her and began CPR, the hospital had been notified. The transport team deliv- ered her in minutes. The surgical team took her straight to the operating room and crashed her onto heart-lung bypass. One step followed right after another.
And, because of the speed with which they did, she had a chance. In the ICU, a mechanical ventilator, fluids, and intravenous drugs kept her going while the rest of her body recovered. The next day, the doctors were able to remove her lines and tubes.
The day after that, she was sitting up in bed, ready to go home. They provide a kind of cognitive net. They catch mental flaws inherent in all of us — flaws of memory and attention and thor- oughness. And because they do, they raise wide, unexpected pos- sibilities. But they presumably have limits, as well. Simple problems, they note, are ones like baking a cake from a mix.
There is a recipe. Some- times there are a few basic techniques to learn. But once these are mastered, following the recipe brings a high likelihood of success. Complicated problems are ones like sending a rocket to the moon. They can sometimes be broken down into a series of sim- ple problems. But there is no straightforward recipe. Success frequently requires multiple people, often multiple teams, and specialized expertise.
Unanticipated difficulties are frequent.
Tim- ing and coordination become serious concerns. Complex problems are ones like raising a child. Once you learn how to send a rocket to the moon, you can repeat the pro- cess with other rockets and perfect it. One rocket is like another rocket. But not so with raising a child, the professors point out. Every child is unique. Although raising one child may provide experience, it does not guarantee success with the next child.
Expertise is valuable but most certainly not sufficient. Indeed, the next child may require an entirely different approach from the previous one. And this brings up another feature of complex problems: Yet we all know that it is possible to raise a child well. Thinking about averting plane crashes in , or stopping infections of central lines in , or rescuing drowning victims today, I realized that the key problem in each instance was essen- tially a simple one, despite the number of contributing factors.
One needed only to focus attention on the rudder and elevator controls in the first case, to maintain sterility in the second, and to be prepared for cardiac bypass in the third. We are besieged by simple problems. In medicine, these are the failures to don a mask when putting in a central line or to recall that one of the ten causes of a flat-line cardiac arrest is a potassium overdose. In legal practice, these are the failures to remember all the critical avenues of defense in a tax fraud case or simply the various court deadlines.
In police work, these are the failures to conduct an eyewitness lineup properly, forgetting to tell the witness that the perpetrator of the crime may not be in the lineup, for instance, or having someone present who knows which one the suspect is. Checklists can provide protection against such elementary errors. Much of the most critical work people do, however, is not so simple. Putting in a central line is just one of the tasks an ICU team must coordinate and execute in a day — ICU work is complicated — and are we really going to be able to create and follow checklists for every possible one of them?
Is this even remotely practical? There is no straightforward recipe for the care of ICU patients. It requires multiple practitioners orchestrating different combinations of tasks for different conditions — matters that cannot be controlled by simple forcing functions. Plus, people are individual in ways that rockets are not — they are complex.
No two pneumonia patients are identical. Even with the same bacteria, the same cough and shortness of breath, the same low oxygen levels, the same antibiotic, one patient might get better and the other might not. A doctor must be prepared for unpredictable turns that checklists seem completely unsuited to address. For- get the paperwork. I have been thinking about these matters for a long time now.
I want to be a good doctor for my patients. You want people to make sure to get the stupid stuff right. Yet you also want to leave room for craft and judgment and the ability to respond to unexpected difficulties that arise along the way.
The value of checklists for simple problems seems self- evident. But can they help avert failure when the problems com- bine everything from the simple to the complex? I happened across an answer in an unlikely place. I found it as I was just strolling down the street one day.
It was a bright January morning in I was on my way to work, walking along the sidewalk from the parking lot to the main entrance of my hospital, when I came upon a new building under construction for our medical center. It was only a skele- ton of steel beams at that point, but it stretched eleven stories high, occupied a full city block, and seemed to have arisen almost overnight from the empty lot that had been there.
I stood at one corner watching a construction worker welding a joint as he bal- anced on a girder four stories above me. And I wondered: How did he and all his co-workers know that they were building this thing right? The building was not unusually large.
The building, he said, would be , square feet in size, with three stories underground in addition to the eleven stories above. The construction workers would have to dig out , cubic yards of dirt and install 64, feet of copper piping, forty-seven miles of conduit, and ninety-five miles of electrical wire — enough to reach Maine. When I was eleven years old, growing up in Athens, Ohio, I decided I was going to build myself a bookcase.
With the help of the nice man with hairy ears behind the counter, I bought four pine planks, each eight inches wide and three-quarters of an inch thick and cut to four feet long. I also bought a tin of stain, a tin of varnish, some sandpaper, and a box of common nails. I lugged the stuff home to our garage. I carefully measured my dimensions. Then I nailed the two cross planks into the two side planks and stood my new bookcase up.
It looked perfect. I sanded down the surfaces, applied the stain and soon the varnish. Then I watched the whole thing fall sideways like a drunk tipping over. The two middle boards began pulling out. So I hammered in a few more nails and stood the bookcase up again.
It tipped over the other way. I banged in some more nails, this time coming in at an angle, thinking that would do the trick. It didn't. Finally, I just nailed the damn thing directly into the wall. And that was how I discovered the concept of bracing. So as I looked up at this whole building that had to stand up straight even in an earthquake, puzzling over how the workers could be sure they were constructing it properly, I realized the question had two components. First, how could they be sure that they had the right knowledge in hand?
Second, how could they be sure that they were applying this knowledge correctly? Both aspects are tricky. In designing a building, experts must take into account a disconcertingly vast range of factors: Then, to turn the paper plans into reality, they presumably face equally byzantine difficulties making sure that all the different tradesmen and machinery do their job the right way, in the right sequence, while also maintaining the flexibility to adjust for unexpected difficulties and changes.
Yet builders clearly succeed. They safely put up millions of buildings all over the globe. And they do so despite the fact that construction work has grown infinitely more complex over the decades. Moreover, they do it with a frontline workforce that regards each particular job — from pile-driving to wiring intensive care units — much the way doctors, teachers, and other profes- sionals regard their jobs: I told him I wanted to find out how work is done in his profession.
It turned out I'd come to the right person. It did the structural rebuilding of Fenway Park, the Boston Red Sox baseball team's thirty-six- thousand-seat stadium, including the Green Monster, its iconic thirty-seven-foot, home-run-stealing left field wall. And the firm's particular specialty has been designing and engineering large, complicated, often high-rise structures all over the country.
Salvia's tallest skyscraper is an eighty-story tower going up in Miami. In Providence, Rhode Island, his firm built a shopping mall that required one of the largest steel mill orders placed on the East Coast more than twenty-four thousand tons ; it is also involved in perhaps the biggest commercial project in the world — the Meadowlands Xanadu entertainment and sports complex in East Rutherford, New Jersey, which will house a stadium for the New York Giants and New York Jets football teams, a three- thousand-seat music theater, the country's largest movie multi- plex, and the SnowPark, the nation's first indoor ski resort.
And they have never had a building come even close to collapsing. He told me about the first project he ever designed — a roof for a small shop- ping plaza. He was just out of college, a twenty-three-year-old kid from East Cambridge, which is not exactly where the Harvard profes- sors live.
His father was a maintenance man and his mother worked in a meat processing plant, but he was good in school and became the first member of his family to go to college.
He went to Tuffs University planning to become a doctor. Then he hit organic chemistry class. So I quit. As a result, he switched to engineering, a scientific but practical field, and he loved it. One of its projects was a new shopping mall in Texas, and Salvia was assigned the roof system.
He found he actually understood a lot about how to build a solid roof from his text- books and from the requirements detailed in building codes. And the local building codes spelled out what was required for steel strength, soil com- position, snow-bearing capacity, wind-pressure resistance, and earthquake tolerance. All he had to do was factor these elements into the business deal, which specified the size of the building, the number of floors, the store locations, the loading docks.
As we talked he was already drawing the contours for me on a piece of paper. It started out as a simple rectangle. Then he sketched in the store walls, doorways, walking space. The design began tak- ing form. You check your math to make sure you've met all the requirements. All this he had learned in college. There was the matter of cost, for example, about which he had not a clue. The size and type of materials he put in changed the cost of the proj- ect, it turned out.
Instead, every building is new and indi- vidual in ways both small and large — they are complex — and as a result there is often no textbook formula for the problems that come up. From a structural engineering point of view, Salvia explained, cylinders are problematic. A square provides 60 percent more stiffness than a circle, and in wind or an earthquake a building needs to be able to resist the tendency to twist or bend.
Besides the concerns of costs and aesthetics, he also needed to deal with the requirements of all the other professionals involved. There were the plumbing engineers, the electrical engineers, the mechanical engineers — every one of them wanting to put pipes, wiring, HVAC units just where his support columns were sup- posed to go.
It has a skin. It has a skele- ton. It has a vascular system — the plumbing. It has a breathing system — the ventilation. It has a nervous system — the wiring. He pulled out the construction plans for a four- hundred-foot-tall skyscraper he was currently building and flipped to the table of contents to show me. Each trade had con- tributed its own separate section. There were sections for con- veying systems elevators and escalators , mechanical systems heating, ventilation, plumbing, air conditioning, fire protection , masonry, concrete structures, metal structures, electrical systems, doors and windows, thermal and moisture systems including waterproofing and insulation , rough and finish carpentry, site work including excavation, waste and storm water collection, and walkways — everything right down to the carpeting, painting, landscaping, and rodent control.
All the separate contributions had to be included. Yet they also had to fit together somehow so as to make sense as a whole. And then they had to be executed precisely and in coordination. On the face of it, the complexities seemed overwhelming. To manage them, Salvia said, the entire industry was forced to evolve.
For most of modern history, he explained, going back to medieval times, the dominant way people put up buildings was by going out and hiring Master Builders who designed them, engi- neered them, and oversaw construction from start to finish, por- tico to plumbing.
Master Builders built Notre Dame, St. But by the middle of the twentieth century the Master Builders were dead and gone. The variety and sophistication of advancements in every stage of the construction process had overwhelmed the abilities of any individual to master them. In the first division of labor, architectural and engineering design split off from construction.
The field looked, in other words, a lot like medicine, with all its specialists and superspecialists. Yet we in medicine continue to exist in a system created in the Master Builder era — a system in which a lone Master Physi- cian with a prescription pad, an operating room, and a few peo- ple to follow his lead plans and executes the entirety of care for a patient, from diagnosis through treatment.
In the construction business, Salvia explained, such failure is not an option. No matter how complex the problems he faced in designing that first shopping mall roof, he very quickly under- stood that he had no margin for error. But, whatever the reason, architects, engineers, and builders were forced long ago — going back to the early part of the last century — to confront the fact that the Master Builder model no longer worked.
So they abandoned it. They found a different way to make sure they get things right. His firm happened to have a job under way a short, sunny walk from his office.