Patients receiving improper doses or medications. Doctors making surgical and lab errors. Hospital staff failing to communicate
about follow-up care. The trends, concluded Atul Gawande, MD, were more than a bit disturbing. Despite all of the advancements
in human medicine—revolutionary technology, groundbreaking research, and multimillion-dollar facilities—the human error rate
in patient care hovered at unacceptable levels. And no one could figure out why.
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Dr. Gawande's idea for his book The Checklist Manifesto (Metropolitan Books, 2009) came from trying to understand how medicine could be made better. Dr. Gawande, an associate professor
at Harvard Medical School and a Boston-area surgeon, says the healthcare industry improves by training people longer and introducing
new technologies to get better results. "But despite all the training, human error continued to climb, and we didn't have
any answers," he says.
Dr. Gawande had his suspicions. As human healthcare had grown more complicated, more chaotic, and more technology-driven,
the people in the trenches were losing their way. He had experienced this firsthand through a series of near-disasters in
his and other operating rooms.
INVESTIGATING HUMAN ERROR
What the medical establishment needed, Dr. Gawande was convinced, was a tool to keep it on course—a road map. A complex surgery
is like a long drive down a dark and windy road, and doctors need markers to help them complete the journey. As Dr. Gawande
investigated, he confirmed his theory. Most human error came not from the technical, complicated part of patient care, but
from the mundane side. Poor bandaging, erroneous medication doses, central lines inserted incorrectly—all were errors resulting
from tasks that should have been second nature to those performing them.
So what went wrong in those situations? The answer was simple. "A lot of the struggles in our healthcare system arise because
we've had a vast increase in the amount of knowledge, capability, and complexity we're expected to manage day to day," Dr.
Gawande says. He began to look at how other highly technical, complex industries handled similar issues. "Areas like aviation
and skyscraper construction require lots of training and use lots of technology," he says. "But they also have a fundamental
tool that they've adapted to help them—a checklist."
The airline industry utilizes detailed checklists for almost every aspect of an airplane's maintenance and use. Skyscraper
designers create checklists for virtually every step of a yearlong construction project. So why couldn't the healthcare industry
do the same?
That became Dr. Gawande's goal. By mapping out the steps involved in a procedure, making sure each team member knew his or
her role, and ensuring that the process was followed through and accounted for, could the industry expect to see an improvement?
Yes. Every hospital that tested the checklist concept saw a reduction in complications and deaths—anywhere from 18 percent
to 47 percent. "A large component of what we do is not about how smart or skilled we are," Dr. Gawande says. "It's about how
well we manage complexity with a group or chain of people who are all responsible for patients."