The Impact of Checklists on Patient Safety
There is resistance to some of the easiest solutions proven to prevent hundreds of thousands of unnecessary patient deaths each year. Why the pushback, and what can be done?
Intro: The man who discovered basic hygiene was mocked by his peers
After graduating from medical school, Ignaz Sammelweis went to work at Vienna General Hospital’s maternity clinic in 1846. In one of his wards, the maternal mortality rate was alarmingly high, ranging between 13-18%, while another ward, staffed by midwives, experienced just 1-2%.
While observing a fellow physician pass away due to what appeared to be a case of childbed fever after cutting himself with a scalpel that had been used in an autopsy of one of the deceased mothers, he had a startling realization: the difference between his ward and the midwives’ was that the physicians in his ward had been conducting autopsies on the dead women with their bare hands and would then deliver babies with those same contaminated bare hands.
While we at the time did not understand the science of bacteria, with his limited knowledge he characterized the source as particles of “decaying animal-organic matter.” Semmelweis concluded the correct solution would be to wash one’s hands before examining a woman in the labor room.
Within just months, the mortality rate of his ward dropped down to 1-2%, matching the midwives’ ward where autopsies were not performed in between deliveries.
You might ask, “OK, I see how this pertains to patient safety, but what does this have to do with checklists?” The answer is that, despite even school children understanding the importance of washing our hands, we are all simply human and forget to do things that we know we must do. It’s more important than ever, with the strain being placed on healthcare providers globally, that even the simplest thing like washing one’s hands, something we take for granted, be done by every healthcare professional who treats a patient, every time without fail.
While it’s human nature to perhaps have empathy with an overworked physician making a mistake we could all make, the bottom line is that, while we may forget to wash our hands with no consequences, it is of mortal importance that those treating patients do not forget.
On the flip side, there are those with years of education and decades of experience who consciously choose not to wash their hands or make it a priority. In 2022. In the middle of a pandemic.
As to our good doctor? He was mocked out of his profession, handwashing did not take hold for decades to come, and our hero died on the operating table from sepsis – that he caught from the surgeon who worked on him.
Why are checklists important in healthcare?
Centers for Disease Control (CDC) reports that healthcare-associated infections (HAIs) affect between five and 10 percent of hospitalized patients in the US each year, resulting in 99,000 deaths and an estimated $20 billion in healthcare costs.
How often do you hear about medical errors or adverse events? If you’re a medical professional, the answer is probably too often. In fact, according to the Institute of Medicine (IOM), medical errors kill at least 98,000 Americans each year.
What do both statistics have in common? They both may be tackled with the simple concept of a checklist.
In fact, the CDC has identified several types of HAIs that can be prevented through the use of checklists. These include central line-associated bloodstream infection, catheter-related urinary tract infection, surgical site infection, and ventilator-associated pneumonia.
Compliance with handwashing, a simple, inarguable method to enhance patient safety, should be a part of comprehensive, safety-first checklists that hold people accountable, provide transparency in medicine, and at the end of the day, save lives.
The Checklist Mortality Rate
In his book The Checklist Manifesto: How to Get Things Right, Dr. Atul Gawande makes the impassioned plea for the greater adoption of checklists by professionals. A well-crafted checklist in complex situations is an incredibly effective tool that ensures potentially fatal errors and dangerous oversights can be caught and avoided.
He gives brow-raising examples and first-hand knowledge where a checklist he or a peer used a checklist to prevent a patient’s death, including a story involving a bayonet at a Halloween costume party, and a routine, low-risk surgery where the patient nearly bled out, only to be saved by the author’s habit of sticking to his checklist, no matter how seemingly unnecessary, which ensured the amount of blood necessary to prevent the patient’s death was readily on hand.
There have been studies on checklist performance as it pertains to mortality rates. A systemic review of non-randomized controlled trials, in fact, finds that checklists in these trials reduced patient 30-day mortality by up to 40%. The trials ran the gamut of patient care: citations reported evaluations of checklists designed to improve surgical safety, prescription of medications, heart failure management, pain control, infection control precautions, and physician handover.
One study carried out by critical care specialist Peter Pronovost, called the Keystone Initiative, aimed to reduce the number of infections from central line catheters inserted into the veins of intensive care patients. Central lines are easily and frequently infected (for example, by being touched with unsterilized hands), causing potentially lethal complications for patients. Pronovost employed a checklist to see if it would reduce infections. It was a success; the initiative ended up saving $175 million and 1,500 lives over 18 months.
Drawing inspiration from Pronovost and the fields of engineering and aviation, the author and the World Health Organization developed a checklist to be tested in eight hospitals around the world, in what was named the Safe Surgery Saves Lives program. The hospitals were asked to use this surgical checklist, which consisted of nineteen essential items ranging from discussing the patient’s expected blood loss to confirming that they had the correct patient. The results were astounding; deaths from surgeries across the eight hospitals were reduced by 47 percent.
Effective checklists are succinct and easily understood
Checklists don’t need to be complex to be used in a complex situation. On the contrary, Dr. Gawande argues, checklists should be as short as possible, include all essential steps, and leave no room for misunderstandings. One essential aspect of a checklist is that it contains the “killer items” of the procedure. These are the steps that are easily disregarded but, if not completed, could be disastrous. For example, this could be a reminder to identify a patient’s allergies before surgery, or even to wash one’s hands.
Although they should contain all essential items, checklists should not be thorough guides. Daniel Boorman, a veteran pilot who creates aviation checklists for Boeing, says that around five to nine items are ideal, and there should be a time limit on how long it takes to go through the list. After around one minute of reading a list, people can become distracted and skip vital steps.
One of Dr. Gawande’s key points in his book was this: a checklist can be an incredibly effective tool for professionals and experts, it is not a to-do list for the inept.
So what’s the catch?
The fact is, checklist adoption is not where it should be. With checklists comes transparency, and with transparency, there comes accountability. And to some folks, this is perceived as control. Unwanted control. To others, it’s not a priority during heavy workloads. There isn’t consistency in how they’re applied and no team culture that encourages disciplined adherence.
Between 2009 and 2010, Dr. Michael Rose, an anesthesiologist and VP of Surgical Services at McLeod Regional Health System in Florence, South Carolina, worked to overcome the resistance from his surgical teams in deploying a checklist designed to reduce errors and improve outcomes.
Even armed with a wide range of clear and compelling data, resistance came in the forms of apathy, doubt, hopelessness, rejection, and duplicitous support. And despite over a year of sharing that data, training, marketing its benefits, persuading or cajoling colleagues, and even manding its use, adoption rates stalled at 30%. So he changed tactics: he stopped focusing on the resisters, stopped telling folks what to do, and instead focused on those committed to change, creating alliances and working from the inside out of the groups he needed to bring on board. And instead of just buy-in, he sought “ownership” from his allies, leading them to commit to assisting in enacting change, not just agreeing to it and taking credit when others achieve it.
The results? By 2019 the numbers proved him right. With a 100% adoption rate of checklists by his surgeons, 30-day mortality rate dropped by a third, productivity increased by 7.5 hours per case, and he was saving $4m annually.
One city down – too many to go.
The Challenges Ahead
As with Ignaz Sammelweis, checklists are still fighting for their place among the most obvious, clearly beneficial, and life-saving tools available to medical professionals. With hundreds of thousands of people in the US alone dying from easily avoidable situations, the government has taken note and begun to get more granular in their compliance requirements, requirements that ultimately decide if a medical facility can participate in Medicaid or Medicare, beyond just saving lives.
Even well-intentioned, seasoned professionals run the risk of contributing to non-compliance, and to that end, thanks to the ever-forward marching of technology, many solutions acting as digital checklists have sprouted up, automating both repetitive and complex processes, and focused on helping medical facilities stay compliant.
But with humanity also comes greed and avarice, and those resisting the opportunity to do good for their fellow human due to ego, hubris, or something else, will look for any way to avoid the responsibility that is thrust upon them when digital checklists force transparency and accountability on them.
There are efforts both in the free market and in government to overcome these challenges by providing bullet-proof tools on one side and creating life-saving laws on the other. And as in all things, there are those on both sides who will resist.
The stakes are already high. People are dead that could have easily and cheaply been saved if not for the mistakes of those from whom they sought help and wellness, and it won’t stop until we build into our healthcare system the transparency and accountability, leading to responsibility, that is necessary.
We’re here to hold accountable those in power who willingly contribute to unavoidable and unnecessary patient deaths, and we hope you’ll help us in that mission. Educate yourself on what these critical issues are, and demand from those who can the commitment from them to act.