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Another industry faced systemic life-and-death problems like this. Air travel. They use extensive checklists that they run like human computers before every fli

Another industry faced systemic life-and-death problems like this. Air travel. They use extensive checklists that they run like human computers before every flight, from the smallest cessna to the largest airbus. My mom, the NP, says doctors, as a group are too proud to ever use lists like that. She asked me how the "pride issue" was dealt with among pilots. I suggested that when it comes to airplanes, prideful pilots have a way of sorting themselves out one way or another. Source: I'm a timid GA pilot who actually shouted "I'm a leaf on the wind" at my plane during my first solo...

wvenable 10y ago
I'd argue that there so many differences between air travel and medicine that it's not a useful comparison. A single passenger doesn't even interact with a Pilot, as just one example.
- TillE 10y ago
  It's not difficult to see how the concept of following strict procedures and double-checking your work might be adapted to medicine. There's really no use in arguing about an analogy. Focus on the point.
  - wvenable 10y ago
    It sort of implies that there aren't strict procedures and double-checking in medicine. But there are. The problem is that medicine is more complicated with more people involved. You can't just say "hey, look in Engineering we can build bridges on time and under budget, why can't you do that with software?" The same issue here.
    - EliRivers 10y ago
      I understand the evidence indicates that checklists in medicine can make a significant improvement. http://www.who.int/patientsafety/implementation/checklists/background/en/ http://www.who.int/patientsafety/implementation/checklists/b... "This study revealed an overall significant reduction in mortality and morbidity after implementation of the checklist."
tomkinstinch 10y ago
There is a push to use 'pilot' checklists in medicine as tools for reducing human error! Harvard surgeon Atul Gawande wrote a book on it: http://atulgawande.com/book/the-checklist-manifesto/ http://atulgawande.com/book/the-checklist-manifesto/ http://www.amazon.com/Checklist-Manifesto-How-Things-Right/dp/0805091742 http://www.amazon.com/Checklist-Manifesto-How-Things-Right/d...
matwood 10y ago
Interesting. I sat in on a few surgeries years ago when I thinking about going pre-med and I saw many checklists. There were counts of instruments used, rags used, checking and double checking all through the surgery. Maybe it was only these 2 older surgeons who did this, but it seemed pretty useful. I distinctly remember having a hanging shoe rack like thing where each rag used was put to make counting easy. The count was off at the end of one of the surgeries so they went through it again, and it turned out one of the slots had 2 rags.
- schoen 10y ago
  I was just in a hospital lab and saw a very prominent checklist on the wall for use with some procedures (but not what I was there for, so I didn't see whether they used the checklist in practice).
- digler999 10y ago
  counting the instruments/sponges is not the kind of checklist they are referring to. They mean "I'm going to do an appendectomy: sterile instruments [X], wash hands[X], open instrument pack [X], apply iodine solution [X], make 4cm abdominal incision [X]....
strictnein 10y ago
My father was a private pilot. Owned a plane (1996(?) Mooney Bravo, it really moved), so we flew around quite a bit. If I got in a small plane, and the guy I was flying with wasn't going through his checklist, I would get out.
CreRecombinase 10y ago
The issue is that medicine is not air travel. For example, if an airplane doesn't pass safety checks that plane doesn't fly. What is the equivalent in the ER? Furthermore, because of the way planes are engineered, (and because of the stringent safety standards), it is rarely the case that a mechanic has to make repairs on an already compromised vehicle, and even in that scenario most systems are designed to fail independently of other systems (i.e the fact that the electrical system is on the fritz doesn't change the way you inspect the propeller). In the medical realm, all of the systems interact. Reducing blood pressure may put undue stress on the kidneys, etc, so any hypothetical flow-chart is going to get really complicated really fast. The issue is partially pride, but it's also that it's not obvious that blindly adding checklists makes sense in every scenario.
- rpedela 10y ago
  I don't know if checklists can be used in every medical scenario, but they do have a significant positive effect in surgery [1]. 1. http://www.nytimes.com/2009/01/20/health/20surgery.html?_r=0 http://www.nytimes.com/2009/01/20/health/20surgery.html?_r=0
  - nefitty 10y ago
    I think checklists can be used in literally almost any scenario. They can prevent basic errors from occurring, and can save time on unnecessary redundancy. I'm not sure what the process would be for a medical procedure but it could be 1. Admit patient 2. Consult about problem 3. Decide effective treatment 4. Perform and run through checklist of that treatment. Each step would have it's own checklist that follows the patient and that can be seen and reviewed by other caregivers. Checklists have made my life easier. For example, I got in to work today and if I hadn't made a checklist of my daily procedure I might be stuck on HN all day, but just looking over today's tasks I know what my first step and final steps look like so I can begin immediately upon entering the building. If I make a mistake I won't kill anyone, but if my life is in someone's hands I'd very much hope that they are running through a checklist built around the priority of keeping me alive first, and making me healthy second.
- 10y ago
shimon 10y ago
The sorting out is exactly the problem. A mistake in an aircraft, combined with some bad luck, leads to a crash. Everyone knows what that is and it triggers a government review. In medicine, most mistakes are not obvious. A doctor who makes 5 or 10 times as many mistakes as average might be known to a few colleagues as "that guy who probably shouldn't have his license", but the vast majority of those won't even lead to malpractice cases, let alone clear-cut malpractice verdicts. That said, we should be engaged in understanding and judging these cases, and figure out how to properly attribute deaths to preventable medical errors. It will be messy but the status quo is a large-scale ongoing disaster.
- lisper 10y ago
  > A mistake in an aircraft, combined with some bad luck, leads to a crash. Not always. You can actually push your luck pretty hard in an airplane and get away with it 99% of the time. There are pilots out there who are accidents waiting to happen.
  - jleader 10y ago
    Example where the pilots involved pushed their luck until that 1% chance finally killed them (and their passengers): http://fearoflanding.com/accidents/accident-reports/how-to-drop-a-gulfstream-iv-into-a-ravine-habitual-noncompliance/ http://fearoflanding.com/accidents/accident-reports/how-to-d...
  - jandrese 10y ago
    The point is that there is almost never a single cause for any accident. It is almost always due to a confluence of multiple events. This should be expected. Engineers can be reasonably expected to think of the contingencies related to the system they are actively working on, but generally work under the assumption that the rest of the device is functioning normally. A nonfatal error in a normal situation can become fatal when combined with two or three other nonfatal conditions.
brazzledazzle 10y ago
You'd think with the embarrassing history (as a profession) of being too prideful to do things like wash their hands there would be a bit more humility.
robohamburger 10y ago
This seems like a really good idea. Otherwise brilliant and highly trained humans make mistakes. Any process or plan that requires everything going perfect as the only acceptable outcome seems like a terrible one.
marcosdumay 10y ago
Air travel also does not overwork their professionals as a rule, and have a clear policy of liability waving from parties that did not practice negligence or willful malpractice (just like the GP is asking for). On the other hand, any accident carries a huge cost that companies can not wave away, because it is not set by tribunals. I really don't know what factor it the most relevant here.
grahamburger 10y ago
Do you think that the air travel industry's roots in the military is a significant factor? I would guess so but I have no experience to back it up, just curious. (I'm asking this on the assumption that the US air travel industry has significant military roots, which I think is true but could be wrong?)
- eru 10y ago
  If that is a factor, looking at how the military does medicine might be instructive.
maxcan 10y ago
I'm a timid GA pilot too and you're absolutely right. Another big differentiator is the way accidents and liability is managed. When a pilot makes a mistake, they file an ASRS report and instead of being disciplined or hit with a huge legal liability they can be open and transparent while NASA and the FAA work to mitigate those accidents from happening in the future. Unfortunately, no such system exists in healthcare. Physicians and hospitals have every incentive to cover up mistakes and hope they don't reoccur instead of reporting them and ensuring that they dont.
- ska 10y ago
  This can't be overstated. I'm not sure the risk profile in medicine is similar enough to expect the same magnitude of improvement that aviation got. I am sure, however, that the systematic way of viewing errors as an opportunity for improvement and transparent evaluation, rather than an opportunity for blame throwing and obfuscation, was absolutely key to the success of ASRS and related. The key takeaway isn't a checklist system, it it is the report and reviewing that arrived at what is on the checklist, and why.
  - maxcan 10y ago
    Exactly. The checklist is actually a product of the solution - transparent reporting and rigorous analysis of those reports. Unfortunately, the healthcare system is basically cargo-culting checklists without putting in place the underlying processes to get to the "right" checklist. Or perhaps a solution that is even better for healthcare than checklists.
    - sokoloff 10y ago
      There's significant argument in aviation community about how checklists should be designed as well. I personally don't think an 8-page checklist (6 pages for normals) to fly a Piper Cherokee or Cessna 172 is the safest approach or most sensible operational tool. Many pilots seem to agree and make up their own checklists that they actually use with only the "killer items" and I think that probably increases safety; certainly it increases safety over the 8 page checklist that stays in the map pocket for the whole flight. Why doesn't the factory do that? Well, if they remove something from a checklist and a pilot comes to grief, they're thinking of how it will look in a courtroom. "No charge to add something to the list..." You'd probably enjoy reading Checklist Manifesto by Dr Atul Gawande: http://amzn.to/1ZlTjoJ http://amzn.to/1ZlTjoJ I read it years ago, but I seem to recall he did cover some of the processes and social aspects of checklist usage.
greedo 10y ago
There are old pilots, and bold pilots, but not too many old, bold pilots...

wvenable 10y ago

I'd argue that there so many differences between air travel and medicine that it's not a useful comparison. A single passenger doesn't even interact with a Pilot, as just one example.

TillE 10y ago
It's not difficult to see how the concept of following strict procedures and double-checking your work might be adapted to medicine. There's really no use in arguing about an analogy. Focus on the point.
- wvenable 10y ago
  It sort of implies that there aren't strict procedures and double-checking in medicine. But there are. The problem is that medicine is more complicated with more people involved. You can't just say "hey, look in Engineering we can build bridges on time and under budget, why can't you do that with software?" The same issue here.
  - EliRivers 10y ago
    I understand the evidence indicates that checklists in medicine can make a significant improvement. http://www.who.int/patientsafety/implementation/checklists/background/en/ http://www.who.int/patientsafety/implementation/checklists/b... "This study revealed an overall significant reduction in mortality and morbidity after implementation of the checklist."

tomkinstinch 10y ago

There is a push to use 'pilot' checklists in medicine as tools for reducing human error! Harvard surgeon Atul Gawande wrote a book on it: http://atulgawande.com/book/the-checklist-manifesto/ http://atulgawande.com/book/the-checklist-manifesto/ http://www.amazon.com/Checklist-Manifesto-How-Things-Right/dp/0805091742 http://www.amazon.com/Checklist-Manifesto-How-Things-Right/d...

matwood 10y ago

Interesting. I sat in on a few surgeries years ago when I thinking about going pre-med and I saw many checklists. There were counts of instruments used, rags used, checking and double checking all through the surgery. Maybe it was only these 2 older surgeons who did this, but it seemed pretty useful. I distinctly remember having a hanging shoe rack like thing where each rag used was put to make counting easy. The count was off at the end of one of the surgeries so they went through it again, and it turned out one of the slots had 2 rags.

schoen 10y ago
I was just in a hospital lab and saw a very prominent checklist on the wall for use with some procedures (but not what I was there for, so I didn't see whether they used the checklist in practice).
digler999 10y ago
counting the instruments/sponges is not the kind of checklist they are referring to. They mean "I'm going to do an appendectomy: sterile instruments [X], wash hands[X], open instrument pack [X], apply iodine solution [X], make 4cm abdominal incision [X]....

strictnein 10y ago

My father was a private pilot. Owned a plane (1996(?) Mooney Bravo, it really moved), so we flew around quite a bit. If I got in a small plane, and the guy I was flying with wasn't going through his checklist, I would get out.

CreRecombinase 10y ago

The issue is that medicine is not air travel. For example, if an airplane doesn't pass safety checks that plane doesn't fly. What is the equivalent in the ER? Furthermore, because of the way planes are engineered, (and because of the stringent safety standards), it is rarely the case that a mechanic has to make repairs on an already compromised vehicle, and even in that scenario most systems are designed to fail independently of other systems (i.e the fact that the electrical system is on the fritz doesn't change the way you inspect the propeller). In the medical realm, all of the systems interact. Reducing blood pressure may put undue stress on the kidneys, etc, so any hypothetical flow-chart is going to get really complicated really fast. The issue is partially pride, but it's also that it's not obvious that blindly adding checklists makes sense in every scenario.

rpedela 10y ago
I don't know if checklists can be used in every medical scenario, but they do have a significant positive effect in surgery [1]. 1. http://www.nytimes.com/2009/01/20/health/20surgery.html?_r=0 http://www.nytimes.com/2009/01/20/health/20surgery.html?_r=0
- nefitty 10y ago
  I think checklists can be used in literally almost any scenario. They can prevent basic errors from occurring, and can save time on unnecessary redundancy. I'm not sure what the process would be for a medical procedure but it could be 1. Admit patient 2. Consult about problem 3. Decide effective treatment 4. Perform and run through checklist of that treatment. Each step would have it's own checklist that follows the patient and that can be seen and reviewed by other caregivers. Checklists have made my life easier. For example, I got in to work today and if I hadn't made a checklist of my daily procedure I might be stuck on HN all day, but just looking over today's tasks I know what my first step and final steps look like so I can begin immediately upon entering the building. If I make a mistake I won't kill anyone, but if my life is in someone's hands I'd very much hope that they are running through a checklist built around the priority of keeping me alive first, and making me healthy second.
10y ago

shimon 10y ago

The sorting out is exactly the problem. A mistake in an aircraft, combined with some bad luck, leads to a crash. Everyone knows what that is and it triggers a government review. In medicine, most mistakes are not obvious. A doctor who makes 5 or 10 times as many mistakes as average might be known to a few colleagues as "that guy who probably shouldn't have his license", but the vast majority of those won't even lead to malpractice cases, let alone clear-cut malpractice verdicts. That said, we should be engaged in understanding and judging these cases, and figure out how to properly attribute deaths to preventable medical errors. It will be messy but the status quo is a large-scale ongoing disaster.

lisper 10y ago
> A mistake in an aircraft, combined with some bad luck, leads to a crash. Not always. You can actually push your luck pretty hard in an airplane and get away with it 99% of the time. There are pilots out there who are accidents waiting to happen.
- jleader 10y ago
  Example where the pilots involved pushed their luck until that 1% chance finally killed them (and their passengers): http://fearoflanding.com/accidents/accident-reports/how-to-drop-a-gulfstream-iv-into-a-ravine-habitual-noncompliance/ http://fearoflanding.com/accidents/accident-reports/how-to-d...
- jandrese 10y ago
  The point is that there is almost never a single cause for any accident. It is almost always due to a confluence of multiple events. This should be expected. Engineers can be reasonably expected to think of the contingencies related to the system they are actively working on, but generally work under the assumption that the rest of the device is functioning normally. A nonfatal error in a normal situation can become fatal when combined with two or three other nonfatal conditions.

brazzledazzle 10y ago

You'd think with the embarrassing history (as a profession) of being too prideful to do things like wash their hands there would be a bit more humility.

robohamburger 10y ago

This seems like a really good idea. Otherwise brilliant and highly trained humans make mistakes. Any process or plan that requires everything going perfect as the only acceptable outcome seems like a terrible one.

marcosdumay 10y ago

Air travel also does not overwork their professionals as a rule, and have a clear policy of liability waving from parties that did not practice negligence or willful malpractice (just like the GP is asking for). On the other hand, any accident carries a huge cost that companies can not wave away, because it is not set by tribunals. I really don't know what factor it the most relevant here.

grahamburger 10y ago

Do you think that the air travel industry's roots in the military is a significant factor? I would guess so but I have no experience to back it up, just curious. (I'm asking this on the assumption that the US air travel industry has significant military roots, which I think is true but could be wrong?)

eru 10y ago
If that is a factor, looking at how the military does medicine might be instructive.

maxcan 10y ago

I'm a timid GA pilot too and you're absolutely right. Another big differentiator is the way accidents and liability is managed. When a pilot makes a mistake, they file an ASRS report and instead of being disciplined or hit with a huge legal liability they can be open and transparent while NASA and the FAA work to mitigate those accidents from happening in the future. Unfortunately, no such system exists in healthcare. Physicians and hospitals have every incentive to cover up mistakes and hope they don't reoccur instead of reporting them and ensuring that they dont.

ska 10y ago
This can't be overstated. I'm not sure the risk profile in medicine is similar enough to expect the same magnitude of improvement that aviation got. I am sure, however, that the systematic way of viewing errors as an opportunity for improvement and transparent evaluation, rather than an opportunity for blame throwing and obfuscation, was absolutely key to the success of ASRS and related. The key takeaway isn't a checklist system, it it is the report and reviewing that arrived at what is on the checklist, and why.
- maxcan 10y ago
  Exactly. The checklist is actually a product of the solution - transparent reporting and rigorous analysis of those reports. Unfortunately, the healthcare system is basically cargo-culting checklists without putting in place the underlying processes to get to the "right" checklist. Or perhaps a solution that is even better for healthcare than checklists.
  - sokoloff 10y ago
    There's significant argument in aviation community about how checklists should be designed as well. I personally don't think an 8-page checklist (6 pages for normals) to fly a Piper Cherokee or Cessna 172 is the safest approach or most sensible operational tool. Many pilots seem to agree and make up their own checklists that they actually use with only the "killer items" and I think that probably increases safety; certainly it increases safety over the 8 page checklist that stays in the map pocket for the whole flight. Why doesn't the factory do that? Well, if they remove something from a checklist and a pilot comes to grief, they're thinking of how it will look in a courtroom. "No charge to add something to the list..." You'd probably enjoy reading Checklist Manifesto by Dr Atul Gawande: http://amzn.to/1ZlTjoJ http://amzn.to/1ZlTjoJ I read it years ago, but I seem to recall he did cover some of the processes and social aspects of checklist usage.

greedo 10y ago

There are old pilots, and bold pilots, but not too many old, bold pilots...