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I work on software related to medical drilling. Nurses run through simulations (mostly a situation where something has gone wrong) and get graded. It baffled m

I work on software related to medical drilling. Nurses run through simulations (mostly a situation where something has gone wrong) and get graded. It baffled me to learn that this is NOT the norm at hospitals. Due to the stress of a situation-gone-awry and inexperience, some horrific things can happen.[0][1] In some situations you may only have a few minutes to enact corrective procedures. In any case without checklists (and without experience from running routine simulations) it's very easy to make mistakes or forget what to do. I thought the checklists themselves were standard but it appears not...? The more I learn about hospitals' operating practice the more wary I become. I have no idea why hospitals aren't like the aviation industry and have checklists and expiring certifications. (Or maybe I heard wrong and I'm just completely wrong here.) [0]: https://www.telegraph.co.uk/news/2018/05/10/premature-baby-decapitated-mothers-womb-gynaecologist-pulled/ https://www.telegraph.co.uk/news/2018/05/10/premature-baby-d... [1]: https://www.nbcbayarea.com/news/local/Dental-Anesthesia-Under-Scrutiny-After-Child-Dies-381594491.html https://www.nbcbayarea.com/news/local/Dental-Anesthesia-Unde... > Mead said the principal risk is a patient’s airway. He explained that a child’s breathing tube can collapse without warning under sedation. > “It happens instantaneously,” he said. “You have maybe half a minute to make critical decisions about how you're going to manage that child's airway. You can't do that if you don't have somebody competent there helping you.”

cwbrandsma 7y ago
I was part of a start-up developing checklist for high risk pregnancies. The checklists were developed by some of the best doctors in the country, who had already proved the worth of using checklists in their own practice. Even with all of that, we had unending push back from every single hospital we talked to. Eventually it killed the company because deals could not be closed. I still hear of hospitals saying they want checklists, and they keep saying that until they see one, and then they don't want it anymore. Also, it wasn't a cost issue. The package was pretty cheap all told. The push back was in the "system getting in the way"...which was kind of the point unfortunately.
- istjohn 7y ago
  Atul Gawande talks about the importance of developing checklists collaboratively with the people who will use them as opposed to imposing them top down.
flukus 7y ago
I was surprised too, I worked on software for Surgery checklists a decade ago and thought it was standard practice and that only our digitization of it was new, the effects of a checklist have been known for quite a while now. The software I worked on would track every instrument and screw taken into a theatre (using hand scanners), the doctor would have his list of steps for the procedure and the equipment necessary, standard emergency packages were available for the exceptions, etc. It's not just for the direct patients either, some disease can survive instrument sterilization so knowing who else they've been used on can be important.
carbocation 7y ago
Many procedures in hospitals are checklist-driven. Peter Pronovost had an early, high-impact publication on the topic of bloodstream infection prevention with checklists: https://www.nejm.org/doi/full/10.1056/NEJMoa061115 https://www.nejm.org/doi/full/10.1056/NEJMoa061115
amitport 7y ago
In the aviation industry pilots rarely get sued personally. IMO, the issue is more about legal system than it is about the medical one.
- howard941 7y ago
  The solution may be found in the legal system and its corresponding arm, the malpractice insurers, if both were to mandate a minimal standard of care including the use of checklists.
  - amitport 7y ago
    I agree with the first part, but not with your conclusion. There is way too much litigation. Hospitals and staff are using defensive legal strategies-- obscuring docs, discouraging internal (written) investigation, delaying urgent treatment with unneeded consultation (to get more signatures on a decision). IMO, there should be legal protection against malpractice lawsuits. Increasing the attack surface will not help with the core problem: Doctors are over-worked, they are human and they make mistakes. The solution is to either enforce work conditions for doctors (and people die) or accept those mistakes (and people don't get money when they are on the wrong side of statistics)
    - Scoundreller 7y ago
      So who else should be untouchable? What purpose does suing anyone for anything serve? I don’t see too many doctors demanding to become employees (with far less personal liability) instead of independent contractors as they usually are. Getting the best of both worlds is asking for a lot.
      - amitport 7y ago
        I didn't mean to say that they should be "untouchable". Only that they should be given some protection for some very human, systematic, (unavoidable?,) mitigating factors
    - deleted 7y ago

cwbrandsma 7y ago

I was part of a start-up developing checklist for high risk pregnancies. The checklists were developed by some of the best doctors in the country, who had already proved the worth of using checklists in their own practice. Even with all of that, we had unending push back from every single hospital we talked to. Eventually it killed the company because deals could not be closed. I still hear of hospitals saying they want checklists, and they keep saying that until they see one, and then they don't want it anymore. Also, it wasn't a cost issue. The package was pretty cheap all told. The push back was in the "system getting in the way"...which was kind of the point unfortunately.

istjohn 7y ago
Atul Gawande talks about the importance of developing checklists collaboratively with the people who will use them as opposed to imposing them top down.

flukus 7y ago

I was surprised too, I worked on software for Surgery checklists a decade ago and thought it was standard practice and that only our digitization of it was new, the effects of a checklist have been known for quite a while now. The software I worked on would track every instrument and screw taken into a theatre (using hand scanners), the doctor would have his list of steps for the procedure and the equipment necessary, standard emergency packages were available for the exceptions, etc. It's not just for the direct patients either, some disease can survive instrument sterilization so knowing who else they've been used on can be important.

carbocation 7y ago

Many procedures in hospitals are checklist-driven. Peter Pronovost had an early, high-impact publication on the topic of bloodstream infection prevention with checklists: https://www.nejm.org/doi/full/10.1056/NEJMoa061115 https://www.nejm.org/doi/full/10.1056/NEJMoa061115

amitport 7y ago

In the aviation industry pilots rarely get sued personally. IMO, the issue is more about legal system than it is about the medical one.

howard941 7y ago
The solution may be found in the legal system and its corresponding arm, the malpractice insurers, if both were to mandate a minimal standard of care including the use of checklists.
- amitport 7y ago
  I agree with the first part, but not with your conclusion. There is way too much litigation. Hospitals and staff are using defensive legal strategies-- obscuring docs, discouraging internal (written) investigation, delaying urgent treatment with unneeded consultation (to get more signatures on a decision). IMO, there should be legal protection against malpractice lawsuits. Increasing the attack surface will not help with the core problem: Doctors are over-worked, they are human and they make mistakes. The solution is to either enforce work conditions for doctors (and people die) or accept those mistakes (and people don't get money when they are on the wrong side of statistics)
  - Scoundreller 7y ago
    So who else should be untouchable? What purpose does suing anyone for anything serve? I don’t see too many doctors demanding to become employees (with far less personal liability) instead of independent contractors as they usually are. Getting the best of both worlds is asking for a lot.
    - amitport 7y ago
      I didn't mean to say that they should be "untouchable". Only that they should be given some protection for some very human, systematic, (unavoidable?,) mitigating factors
  - deleted 7y ago