Tuesday, February 16, 2010

Book Review: The Checklist Manifesto: How to Get Things Right by Atul Gawande

Last night after finishing this book I lay in bed well past my bedtime (and I got to bed late the night before too), and I thought to myself, well this is why I ought to be reading about Canadian politics or etymology before bedtime as those don't keep me awake, keyed up and excited. My brain was spinning round and round and it was forever before I finally fell asleep. So what was this fascinating book that kept me up? A thriller? A weepy? Nope, a book proposing the use of checklists in surgeries.

Now you're probably thinking, huh? Seriously? How could that possibly be interesting? I assure you it really was.

Mostly it's due to Dr. Gawande's writing style which is accessible, simple but not stupid, and how he always finds spot-on comparisons to other fields that are perhaps a bit more widely understood than medicine. For this book he talked about checklists used in flying, construction, and even finance. I had heard about the airplane comparison before I read it, but the construction one in some ways made more sense. I particularly was fascinated by the fact that there's a computer program that after all the subcontractor's specs are entered (electrical, plumbing, HVAC, carpentry), will note all conflicts (such as an outlet planned to be in the middle of a doorway).

Naturally with the flying comparisons everyone will think of "The Miracle on the Hudson" and rest assured, it is discussed. But a couple of earlier incidents were also detailed and were quite terrifying. A flight from Honolulu to New Zealand had a baggage compartment latch fail, and in less than 2 seconds a huge hole was blown in the side of the plane, sucking a lot of passengers out. One flight attendant's life was saved when a passenger grabbed her ankle. (People seriously, always wear your seat belt when you're sitting.) And the explosion had also ripped out the connections to the oxygen system. So the pilots were oxygen deprived, afraid, and yet were saved by their checklists, and saved the lives of over 150 people on the plane. When something horrible happens, do you want the people in charge to know exactly what to do, even if it's a situation they've never experienced before? Do you want them to be able to hit the most crucial points in their solution, and for those tasks to have been previously practiced, and worked out by experts to find the simplest solution? Or do you want them flying by the seat of their pants, trying to remember something they might have learned 20 years ago, without anyone else's help? Because that's what happens when a catastrophe happens in most surgical rooms today. The surgeon is the boss, the rest of the surgical team is supposed to just do what he/she says, and even if they've seen this particular emergency before it may have been decades earlier. The result isn't always good. But understandable considering how infrequently these complications can arise.

But did you know that the majority of bad outcomes from surgery are a result of simple errors? Doctors not washing their hands before they see you. Not using a sterile dressing on you. Not wanting to change their gloves after having touched something not sterile. Forgetting to give you antibiotics before surgery. These are the issues that the current checklists are designed for and are proven to help rectify. Through a worldwide study these simple tasks were shows to improve mortality and complication rates after surgeries by a third. Not only in India, but also in Seattle and Detroit. I would understand if a complication arose in my surgery but if I were to go in for a simple scope procedure (having a tiny camera threaded down your throat or a vein to look at something inside you) and came out with a 2-foot long incision down my chest because of a typo on my chart that no one pointed out, I'd be livid. (This is an example of a potential error that was caught in one of Dr. Gawande's own procedures thanks to a checklist.)

Such a simple solution. And you know what else is saved besides lives? Money. With the current raging debates on health care and its attendant costs, the savings realized if all hospitals adopted this system could go a long way towards covering all the uninsured. I find it baffling that they don't all adopt this right away, although I can see how if my boss suddenly told me I'd need to go through a checklist daily of the most simple, mundane tasks that I would find it a bit insulting. But with results like these, it seems to prove itself quickly. I think the most interesting detail was that while the majority of doctors definitely thought they themselves didn't need to use the checklists, 91% said if they were to undergo a surgery, they'd want the checklist used. Hmm. I'll definitely be asking my doctor if his hospital uses the Safe Surgery Checklist the next time I need a procedure. In fact, I'm thinking of just giving him this book on my next visit.

This fascinating book has massive potential positive ramifications if only the medical establishment would embrace it. And it was an interesting, fast read to boot.


Amy said...

Great review! Unfortunately, my cousin was on the plane that crashed outside of Buffalo last February, and the crash was due to pilot error. If they had been going through their checklist correctly (and had better training), 51 lives might not have been lost. I totally agree that the checklist is a simple thing that can have many positive benefits!

Carin Siegfried said...

Wow, this is weird. I knew someone on that flight too! A co-worker who was both less than a year from retiring, and also was planning her wedding. She was our highest ranking female exwec,and just a really wonderful woman. So sad about your cousin. Obviously the checklists don't work with everything but actually Gawande admits that they can't checklist every complication. Within medicine he'd just like to checklist the stupid, simple stuff, before even thinking out tackling complications. But there are several examples from flights that are just chilling. His other books are fantastic too if you're interested but think this one might his too close to home still.