Surgical Checklists Don’t Save Lives
Atul Gawande has become famous for The Checklist Manifesto, which makes the case for delivering medical care like The Cheesecake Factory delivers cheesecake. However, David R. Urback and colleagues reported these results:
Implementation of surgical safety checklists in Ontario, Canada, was not associated with significant reductions in operative mortality or complications…
During 3-month periods before and after adoption of a surgical safety checklist, a total of 101 hospitals performed 109,341 and 106,370 procedures, respectively. The adjusted risk of death during a hospital stay or within 30 days after surgery was 0.71% (95% confidence interval [CI], 0.66 to 0.76) before implementation of a surgical checklist and 0.65% (95% CI, 0.60 to 0.70) afterward (odds ratio, 0.91; 95% CI, 0.80 to 1.03; P=0.13). The adjusted risk of surgical complications was 3.86% (95% CI, 3.76 to 3.96) before implementation and 3.82% (95% CI, 3.71 to 3.92) afterward (odds ratio, 0.97; 95% CI, 0.90 to 1.03; P=0.29).
Atul Gawande responds to the checklist study. So does Aaron Carroll.
I like the idea of the surgical checklists. I would assume it makes the surgery more organized for all professionals involved. It may not necessarily save lives, but does it improve efficiency?
I cringed when I read the link that compared delivering health care like the Cheesecake Factory delivers cheesecake. But after clicking and reading Gawande’s article, it is compelling.
However, delivering health care and serving beet salad are two completely different things. Perhaps similar processes are used, but I take this with a grain of salt.
A 3 month period doesn’t seem like quite a long enough time to implement this study. Especially if many of the surgeries are not life threatening.
I agree that more studies should be done on this, however, in higher risk procedures and the study should be done over a longer period of time.
Second
Why do academic researchers and outsiders seem to implicitly assume that that surgical teams are unorganized?
Or that the additional time required for the things that they propose doesn’t impose other harms, like having to sedate the patient longer?
Academic researchers assume that surgical teams are unorganized because they have never been in an operating room feeling the pressure, knowing that every second counts. Researchers don’t have to worry about someone dying if they make a mistake; they just solve everything theoretically and hope that its application is a perfect reflection of their hypothetical study.
I cannot imagine what may cross the mind of a surgeon while operating a patient; it must be a very stressful task knowing that a single mistake can have lasting consequences in the life of the patient. I don’t think surgeons need a checklist in order to successfully operate. I believe that if a rulebook is attached to a procedure, it would have negative consequences. The biggest trait of a surgeon is to be able to work under stressful circumstances adapt to the fast changing events that occur in an operating room. I believe that if the steps are determined, it eventually will hinder the ability of the surgeon to improvise when the conditions of the patient are different from those written in the rulebook.
We probably need a longer period to test the effect.
Massification cannot occur in the healthcare industry. It is a service that is more productive when it’s personalized. I don’t think that having a checklist will improve the safety and success of surgeries. But I’m almost sure that it will decrease quality of the service.
Proponents have long argued that medicine could systematically improve safety. However, there’s nothing magical about checklists; they merely serve as a memory device for use under conditions, when a series of sequential tasks must be performed and memory could fail.
The airline industry has used checklists for years; many safety experts attribute safety improvements in the airline industry to checklists.
But consider how checklists are used in aviation. For instance, to land an airplane involves a series of acquired skills performed as sequential tasks. This includes: maintaining the appropriate pattern altitude, approach speed, power setting, trim setting, flaps setting, carb heat, glide angle, appropriate flare and how to gradually increase the angle of attack until it stalls a foot above the runway and gently sets down. This is not so much a list as it is a set of learned skills.
Landing procedures are a lot to master — and remember. The process is stressful and in the process a pilot can forget something. One small mistake can be catastrophic.
A common checklist acronym used by pilots during landing is GUMPS. This represents: Gas (for safety set selector to both tanks), Undercarriage (make sure the landing gear is down), Mixture (set to full rich in case you need full power), Propeller (set for high RPM in case you need to power-up) and Seatbelts (make sure all passengers are wearing them).
Notice, in the case of aviation, the skills to land a plane have little to do with the checklist acronym. The checklist is just a quick reference of things a pilot may forget in their preoccupation with landing the plane. For instance Wikipedia cites a report that claims pilots crash land about 100 times a year after forgetting to lower their landing gear. The checklist GUMPS is designed to minimize that and other potentially catastrophic memory failures.
Memory devices may help medicine. But an appropriate list would have to be devised for each procedure — and each occasion when it would be needed.