TOPICS > Health

‘Checklist Manifesto’ Author Pairs Simplicity With Lifesaving

February 8, 2010 at 12:00 AM EDT
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Could the straightforward checklists used by airline pilots also help save lives in the operating room? Dr. Atul Gawande's book, "The Checklist Manifesto," examines how lists can reduce risk in the medical field and beyond.

GWEN IFILL: Next: a simple fix for cutting health care costs and saving lives. “NewsHour” health correspondent Betty Ann Bowser explains.

WOMAN: Mr. Wolf has no known drug allergies. He’s not a difficult airway or aspiration risk.

BETTY ANN BOWSER: A 50-year-old man is about to undergo emergency surgery at Brigham & Women’s Hospital in Boston for a dangerous infection in an artery in his leg.

WOMAN: Nice big breaths, in and out. That’s great.

BETTY ANN BOWSER: He’s surrounded by technology and highly skilled doctors and nurses who spent years training for their profession.

WOMAN: You’re doing great.

BETTY ANN BOWSER: But they’re about to employ something breathtakingly simple to make sure Mr. Wolf has a successful outcome. It’s a checklist of 19 points, including making sure everybody in the O.R. introduces themselves.

DR. ED GRAVEREAUX, surgeon: Ed Gravereaux, surgeon.

MAN: Neil Bartos.

MAN: Andy Holtz , surgery resident.

WOMAN: My name is Arti Orie. I’m a seizure resident.

MAN: I’m the attending anesthesiologist.

DR. ED GRAVEREAUX: OK. And this gentleman, we’re performing an excision of an infected femorofemoral bypass graft today. Want to make sure we have any necessary equipment. Looks good, irrigation, a lot of antibiotic irrigation. Pulsavac irrigator.

WOMAN: Pulsavac, check.

WOMAN: Do we have an ultrasound in case we need it?



BETTY ANN BOWSER: Watching all of this was bestselling author and general surgeon at Brigham & Women’s, Dr. Atul Gawande.

DR. ATUL GAWANDE, author, “The Checklist Manifesto”: I never in a million years thought I would be writing a book about checklists.

BETTY ANN BOWSER: But that is what Gawande’s new book, “The Checklist Manifesto: How to Get Things Right,” is about. It grew out of work he did for the World Health Organization, which asked him to help them find a way to reduce deaths in surgery.

DR. ATUL GAWANDE: That was when we came across the idea. We knew we had technology and incredible levels of training, people working unbelievably hard. But we have more than 100,000 deaths just in the United States following surgery. Half are avoidable, from our studies. What could we do?

We have found this idea, this extra tool that others were using in aviation, in skyscraper construction, and thought, well, let’s give it a try.

BETTY ANN BOWSER: After months of research, in 2008, Gawande and his team created the surgical safety checklist for the WHO.

DR. ATUL GAWANDE: We have a pause before the anesthesia is given, and another pause before the incision, and then a pause before the patient leaves the room. We timed it to keep it less than two minutes in a routine operation. And we had — in order to keep it short, that meant that there were some very simple checks, some dumb stuff, make sure an antibiotic is given, make sure blood is available, but then some interesting things, which are much more about having a team prepared for handling the complexity.

BETTY ANN BOWSER: It may be hard to believe, but some of the dumb stuff doesn’t always get done prior to surgery. And Gawande says that is one reason there are so many preventable complications.

DR. ATUL GAWANDE: When we deployed it in eight hospitals around the world — and they range from Seattle, London, Toronto, to poor settings, rural Tanzania, New Delhi, India — each hospital had a reduction in complications. The average reduction was more than a third. And we saw a significant drop in deaths as well.

BETTY ANN BOWSER: And it didn’t matter if the hospital was rich or poor. Gawande argues the simple checklist is effective, because, in today’s high-tech, complex medical world, there is just too much for the human mind to remember.

MAN: It’s fairly standard to use a prosthetic for this — this portion of the procedure and save vein for later.

DR. ATUL GAWANDE: You can take two lessons out of this. One is, you can say, isn’t it terrible how things go wrong? But I think the deeper lesson is the complexity of the world in medicine and beyond has begun to eclipse our abilities, no matter how well trained we are.

We teach medical students, here’s all the stuff in this textbook you’re going to have in your brain. We don’t teach them, guess what? There is going to come a moment where it’s not in your brain, and someone’s life depends on it. What are you going to do?

BETTY ANN BOWSER: Gawande says, studies show 60 percent of pneumonias in America get incomplete or inappropriate care, and that it’s the same for 40 percent of all cases of coronary artery disease.

DR. ATUL GAWANDE: And I will tell you right now, it’s not because we have bad doctors or bad nurses. We have great people, great drugs. But making all of the steps come together in such a way that nothing falls between the cracks, we’re not great at that.

BETTY ANN BOWSER: We interviewed him in an operating room at Brigham & Women’s, where we were required to wear scrubs and hair covering.

When I got through reading this book, I came away with an overwhelming feeling that hospitals are really scary places.

DR. ATUL GAWANDE: Yes. They are scary places. We are deploying 6,000 drugs and 4,000 medical and surgical procedures. And those numbers grow year-to-year.

I started using the surgery checklist, this approach of things, in my operations a couple of years ago. We’re at Harvard. Did I think we needed this? No. And I found I have not gotten through a week without the checklist catching things that made us better, an antibiotic that wasn’t given, blood that was supposed to be available.

I have — I know of at least one patient where I’m certain it saved my patient’s life. It was an operation to remove a tumor that was in his adrenal glands, stuck up against his vena cava, the main blood vessel going back to the heart. And I made the wrong move trying to get it out, and I tore into the vena cava. It is a disastrous thing to happen, probably the worst case I have had, lost his entire blood volume in about 60 seconds.

BETTY ANN BOWSER: But Gawande said, because they had gone through the checklist, there was plenty of blood in the O.R. and equipment to deliver it quickly. So, the patient survived.

And in patient Wolf’s case, the checklist helped the operating room staff realize there were two pieces of critical equipment the surgeon needed and were not on hand. So, they got them before surgery began. Dr. Gawande says, the checklist not only saves lives in the O.R. It has also lowered complications in intensive care units.

DR. ATUL GAWANDE: In Michigan, when the — every hospital there adopted a cleanliness checklist to keep infected lines from happening, they had a two-thirds reduction in infections within a year. They saved more than 1,500 lives and more than $200 million. Spreading this across the country multiplies that by 50-fold.

BETTY ANN BOWSER: In a nation where health care costs are going up faster than inflation, Gawande says that’s something to think about. Currently, the checklist is employed in less than one-quarter of U.S. hospitals.

MAN: And is your belly getting more bloated?


BETTY ANN BOWSER: And Gawande says there has been some resistance to it from those in the medical profession.

DR. ATUL GAWANDE: Our surveys show about 20 percent of surgeons think it’s a waste of time, that it can get in the way. They have had their ways of doing things that have worked perfectly well. What do you mean we — we should work on improving things?

But a couple of things that are the most interesting, when people have tried it, 80 percent find in our surveys that they are actually glad to have it and they wouldn’t go back to doing it any other way.

BETTY ANN BOWSER: With the fate of health care reform legislation up in the air, Dr. Gawande thinks it’s important to push for wider use of the checklist, because it doesn’t cost much to implement and because, he says, it works.