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# Saving 28,000 Lives a Year

263

#### Jane Q. Public (1010737) | more than 5 years ago | (#26029527)

it seems like a good investment.

#### Chapter80 (926879) | more than 5 years ago | (#26030053)

While I'm a firm believer in checklists, I have my doubts about the study. It sounds to me like this might have been conducted by a guy who has a bias toward having checklists (which I do too).

It'd be difficult to measure how many lives were saved by the checklist (as opposed to other factors). I bet he looked at the deaths, and then looked for mistakes in procedures (that could have been avoided with a checklist).

But there are some serious issues with this methodology. Were these patients going to die of something else? Would the checklist have prevented the mistake? And how many patients inadvertently lived due to mistakes that would have died, had checklist procedures been followed?

This message was posted in Slashdot tradition - without reading the article.

### Re:At $107 per life... (5, Informative) #### khanyisa (595216) | more than 5 years ago | (#26030283) Yes the methodology is important - and in this case the article is a fascinating read - basically he compared the number of mistakes beforehand and afterwards, but also looked at the correlation with the number of deaths before hand and afterwards. In this case the causes are a known problem (especially line infections) and they could directly correlate the adoption of checklists with a drop in the incidence of line infections, and subsequently with a lower death rate. Seems like fair enough science to me, and logical as well :-) ### Importantly (-1, Troll) #### QuantumG (50515) | more than 5 years ago | (#26029045) These are American lives, and people with good health insurance to boot. There's no interest in saving the lives of poor people. ### Re:Importantly (4, Insightful) #### DigiShaman (671371) | more than 5 years ago | (#26029145) At least in America, people's ecconomic status in life is in constant change. Someone rich or middle class can be poor while someone poor instantly changes to middle class simply by being employeed with the right company. Anyone who has been stuck eating Ramen for months at a time please raise your hand. God knows how many time's I've been in a funk. Today, I enjoy making around 60k a year. The point I'm trying to make is this. We need to stop looking at people being rich or poor and see them for who they are. Human beings. ### Re:Importantly (-1, Troll) #### QuantumG (50515) | more than 5 years ago | (#26029187) hehehe.. So did mommy and daddy cut off your allowance for a week during college and now you think you know what it's like to come from the streets? ### Re:Importantly (1) #### DigiShaman (671371) | more than 5 years ago | (#26029251) No you jackass! It's called getting hired and then being laid off from work. Last I checked, it's fairly common in the IT world. BTW, why are you trolling? Did someone hi-jack your account or something? ### Re:Importantly (0) #### QuantumG (50515) | more than 5 years ago | (#26029319) Now that you're on the 60k or whatever, I recommend saving. :) BTW, why are you trolling? Did someone hi-jack your account or something? It's either this, or go back to playing Eve Online. I'm not that bored yet. ### Re:Importantly (5, Insightful) #### hairyfeet (841228) | more than 5 years ago | (#26029771) Not to mention the fact that all it takes is a single misstep to fuck you up. Believe me I know. When I was a kid we went from rolling in dough to 3 years on welfare nearly starving. Why? Because my dad who was making damn good money at the time as a special job truck driver(because he could make a semi dance and get it into places that people would swear a truck wouldn't fit) and went to help a fellow driver who had got his load hung up. After he got it loose he went up top to check on the damage and a piece of the top crumpled under him and launched him head first off the roof onto concrete. The medical bills for putting his skull back together, plus the ICU bills quickly blew through the insurance and savings and due to the damage he was not able to work for nearly 3 years. That is why every chance I get I try to help out those that don't have as much as me, and spend a decent chunk of my free time talking SMBs out of and raiding junk shops for PCs that I then rebuild and give to those that don't have one. Knowing that I can use my time and knowledge to make life a little better for a single mom, a kid needing a decent machine to do his homework on, or a small church that uses their donations to help the poor not only gives me a good feeling but makes their lives a little easier and at the same time saves a working PC from becoming just another pile of e-waste in a landfill. For example I helped set up a little network of donated PCs for a battered womens shelter that uses them to teach office skills. So in this Xmas season don't think the only way you have to help is by throwing cash in a charities coffers, there are many ways that someone who knows IT can make someone's life a little easier. Believe me there are plenty of groups out there doing good work whose computers and/or networks are about to fall apart. A little of your time and some donated gear can make a big difference. ### Re:Importantly (0) #### Anonymous Coward | more than 5 years ago | (#26029863) God bless you. You're a better man than I. ### Re:Importantly (0) #### MrMista_B (891430) | more than 5 years ago | (#26029259) Spoken like a true middle-class wealthy white kid who's never worked a day in his life. Do you seriously think that only rich college kids have to eat crap food just to survive sometimes? Something else you gotta realize, QuantumG, is that just because someone's poor, doesn't mean they always have to be poor. Anyone can work harder, better, smarter, and get better in life. ### Re:Importantly (0) #### QuantumG (50515) | more than 5 years ago | (#26029335) Hehe, you don't know shit about me dude. I only went to university because I live in a socialist paradise (Australia). In the USA I'd be mopping floors. The land of opportunity is anything but. ### Re:Importantly (1, Insightful) #### Anonymous Coward | more than 5 years ago | (#26029577) Funny thing about mopping floors... The money you earn can be used to pay for college. It's called earning a living. With a few exceptions, sustained poverty is a self-inflicted condition in the U.S. This is not a troll, this is someone who witnessed his parents bust their asses from dirt-poor up to lower middle-class. Because of their example, I've worked my way from lower middle-class to upper middle-class. I have every confidence that my children will surpass my standard of living and continue the path upward. Unless you have some mental illness or deficiency that prevents you from holding a solid job, your financial future is your own to make (or not). Your "socialist paradise" paid for your education by sending the bill to people who actually earn their keep. ### Re:Importantly (0) #### QuantumG (50515) | more than 5 years ago | (#26029591) Your "socialist paradise" paid for your education by sending the bill to people who actually earn their keep. No actually. They make you pay back every cent, and then some. It just guarantees that everyone gets the same opportunities, not just the kids with parents who can afford to send them. ### Re:Importantly (0) #### Anonymous Coward | more than 5 years ago | (#26029611) Ignore QuantumG, he's a jackass and a troll, things available in plentiful quantities both here in Australia and over there in the US. ### Re:Importantly (1) #### Hognoxious (631665) | more than 5 years ago | (#26030299) Anyone can work harder, better, smarter, and get better in life. I'm not going to say it's not like that. But it's certainly less true than it used to be, even ten or fifteen years ago. These days the middle class is getting squeezed seven ways to Sunday. So apart from being good looking, a good [enough] singer or expert at chasing or hitting a ball around, the routes upward are becoming blocked. And all the time the haves - those who were born with money and connections - are entrenching their position even more. The best decision a kid can make is to choose wealthy parents. ### Re:Importantly (1) #### purplejacket (581360) | more than 5 years ago | (#26029467) In Atul Gawande's book "Better: A Surgeon's Notes on Performance", chapter 2, "The Mop Up", he discusses the program to eliminate polio in India. ### Get rid of the dinosaurs (2, Informative) #### mspohr (589790) | more than 5 years ago | (#26029049) It's amazing how resistant 'modern' medicine is to basic proven work flow improvements such as checklists, treatment guidelines. I think that doctors are the main problem here since they already know everything. The problem is that what they know is out of date, is not practice rigorously, and a lot of their experience is anecdotal evidence which skews their view. They reflexively cry out against 'cookbook' medicine and 'socialized medicine' while ignoring sound scientific advice. We really do need an attitude change here in the same way that Detroit needs an attitude change. (Throw the dinosaurs out.) ### Re:Get rid of the dinosaurs (2, Insightful) #### Daniel Dvorkin (106857) | more than 5 years ago | (#26029345) Having been both a medic and a programmer, I can tell you that "basic proven work flow improvements" are not one-size-fits-all. ### Re:Get rid of the dinosaurs (5, Informative) #### NIckGorton (974753) | more than 5 years ago | (#26029535) They reflexively cry out against 'cookbook' medicine and 'socialized medicine' while ignoring sound scientific advice. Huh? WTF has concerns about cookbook medicine to do with the need for universal access to health care? I am one of those physicians who reflexively cries out FOR universal health insurance. Of course I don't call that 'socialized medicine' because its not different than our 'socialized' school, EMS, Fire, Police, and Highway systems to name a few. And while I think that there are a lot of potential problems with 'cookbook medicine' there are also a lot of potential benefits. Its like any tool that can be used to help or hinder the practice of medicine. For example, an EMR that reminds me my diabetic patient is overdue for annual eye screen and should be on an ACE-Inhibitor is a great idea. However if the same system forces my hand on the ACE-I when I know that patient has had multiple episodes of fainting due to low blood pressure (which an ACE-I would exacerbate) its a problem. Similarly, if I spend all my time inputting data into the EMR it becomes more of a hindrance than a help. In the case of ICU checklists, nurses every year are required to do more and more documentation (an average of 18 pieces of paper for a new non-ICU admission to my hospital) and every checklist or additional page you add to that is taking time away from patient care. So what sounds like a great idea may in fact cause worse outcomes because it puts the nurses focus on a paper rather than their patient. Of course what I always find to be funny is the very same people who have zero tolerance for any risk or error and decry doctors for an untoward fear of cookbook medicine are the first ones to ask you to depart from standard practice for their personal special case... the antibiotics they want for a virus, the expensive lab test or MRI that is really not necessary, the pricey new drug on TV they want when a safer older drug with a proven track record works just as well. That innate lack of trust of health care providers and assumption of laziness or ill will translates to their own relationships with their physician in different but recognizable ways. ### Finally! (1, Funny) #### Anonymous Coward | more than 5 years ago | (#26029061) The medical field has finally taken a hint from the success of the underpants gnomes: Step 1) Create checklist Step 2) ... Step 3) Life Saved! ### Step two (1) #### Weaselmancer (533834) | more than 5 years ago | (#26029775) 2) Follow the checklist and eliminate the 1% error that kills 28,000 patients a day. I know this is /. and you're not expected to read the article. But could you at least read the summary? ### Thanks for the whole picture... (0) #### Anonymous Coward | more than 5 years ago | (#26029105) I don't see how it's anywhere near a "one-time" cost. What if the checklist needs to change? Who controls it? Who approves changes? Are we printing them? Wouldn't HIPAA regulations alone increase the impact caused by adding a new sort of record keeping? Think of the carbon impact this would have, more waste for landfills (or if you're dark, more people consuming and creating waste because they didn't die). ### Re:Thanks for the whole picture... (1) #### zippthorne (748122) | more than 5 years ago | (#26029357) Lemme guess, you're one of those doctors who refuses to wash his hands*, too, because it's somehow demeaning to a man of your stature to do something so ordinary as scrubbing a little suds. *it's on the rise, WTF? ### Re:Thanks for the whole picture... (1) ####$random_var (919061) | more than 5 years ago | (#26029515)

What crawled up your butt? Of course there are operational costs associated with maintaining checklists, but those are a lot less than the cost of creating them, and even more a lot less than the benegits. Now, to answer your questions...
1. then it'll be changed
2. nobody will control all of the checklists in the world; medicine already has processes for developing and disseminating best practices and then on an institution-by-institution basis incorporating those into formal policy. Some such processes include medical journals, seminars, consultants, base studies, and so on.
3. see 2
4. sometimes yes, sometimes they'll be on PDAs. probably somebody will do a study about which is less likely to carry diseases around, and another person will do a study on which costs less.
5. no

### Re:Thanks for the whole picture... (1)

#### NIckGorton (974753) | more than 5 years ago | (#26029699)

2. nobody will control all of the checklists in the world; medicine already has processes for developing and disseminating best practices and then on an institution-by-institution basis incorporating those into formal policy. Some such processes include medical journals, seminars, consultants, base studies, and so on.

Er. No. See: CMS. Case in point: blood cultures before antibiotic administration in sepsis. That is an absolute requirement for the Sepsis bundle and yet there is NO evidence that two sets of cultures does diddly squat to help outcomes. In fact it may theoretically worsen outcomes because you are dicking around waiting for labs to be drawn before you can give the patient with a BP of 70 and a temp of 104 the IV antibiotics they need.

Doctors won't make these rules, the government will (and has so far in the form of payment incentives and penalties courtesy of CMS.)

### Re:Thanks for the whole picture... (1)

#### Hognoxious (631665) | more than 5 years ago | (#26030349)

Are we printing them?

Given the usual standard of doctors' handwriting, I sincerely hope so.

### Look at Airplanes (3, Interesting)

#### corsec67 (627446) | more than 5 years ago | (#26029109)

They use checklists for everything, and flying a plane is much less dangerous than operating on someone in an ICU.

Don't they already have some kinds of checklists for "make sure we don't leave any sponges or scalpels in the patient."

### Re:Look at Airplanes (4, Interesting)

#### evilad (87480) | more than 5 years ago | (#26029201)

Aviation checklist users suffer from a condition that I'll call "known-data blindness" for lack of a better term.

I've run the C-172M checklist several hundred times, and let me tell you, it's *very* easy to lose track of your place in the list, and forget whether your memory of having completed a given item is from this evening's flight, or from the one you did this morning.

This is almost never deadly in a beast as simple as a fixed-prop, fixed-gear Cessna 172. Come to think of it, I've *never* caught a condition with my checklist that would have killed me, had I missed that item.

My personal experience leaves me wondering if it's possible that checklists could cause obvious things to be *missed*.

The problem could be easily fixed with dynamically generated checklists that cannot be answered without having read and comprehended the question... but that would slow things down so much that I bet it would cost more lives than it would save.

### Re:Look at Airplanes (5, Insightful)

#### evanbd (210358) | more than 5 years ago | (#26029451)

In my experience with rocket engine tests, both professionally and as a hobby, I've seen checklists be invaluable tools. I've seen them catch problems that were irrelevant, ones that would have resulted in loss of data, ones that would have resulted in incorrect operation, and ones that had direct safety impacts. However, the problem you describe is very, very common. The simplest solution is quite effective, and they discuss it in the article (but fail to mention how amazingly important it is). You need the person who is responsible for reading the list and making sure each item happens to *not* be the one doing it.

In the article, the nurses follow the checklist and stop the doctors if a step gets missed. At an XCOR Aerospace rocket test, at any given time there is someone whose sole responsibility is reading the checklist (who that is may change through the day, but there always is such a person, and who it is is always clearly defined). In both cases, the person with the checklist has the authority to stop whatever is happening and correct the situation. When I test my hobby rocket motors, the test crew is much more limited (usually two or three people, compared to at least six and often many more at XCOR). As a result, the person reading the checklist is usually also doing things on it. Mistakes are more common, and it's not uncommon to set down the checklist and just do things for a while.

That separation of roles is simple, yet highly effective. Obviously it's a bit hard in a single-pilot airplane. But, in a situation where it's at all possible, it's well worth doing. There are a number of reasons it helps, but one of the simplest is important: the reader can hold the checklist binder with their thumb pointing at the last step completed, since they don't have to use that hand to actually do anything. In the medical case, you're actually making checks on a piece of paper that goes into the file, but the idea is the same.

As an aside, having the checklist be unfamiliar is a bad thing -- mistakes and confusion are much more common after a checklist change. The fix lies in how you use the checklist, not what it says. The reaction to hearing the next step on the list read needs to be "yep, I've already got the tools in my hand" or "oh, right, nearly forgot that" -- not "wait, what was that? Oh, right I was already doing that." If you do that, people will be more inclined to ignore the checklists, because they interfere with operations.

### Re:Look at Airplanes (2, Interesting)

#### evilad (87480) | more than 5 years ago | (#26029493)

Thanks for that. Apparently I skimmed the article a little too quickly. Imagining myself in both positions in the cockpit, I'm inclined to agree. Steps would rarely get missed or performed incorrectly. A far superior system to what I've been doing.

I wonder if delegating checklist-reading to a non-pilot passenger would fall under "good crew-resource management" or "gross negligence".

### Re:Look at Airplanes (1)

#### Mark Hood (1630) | more than 5 years ago | (#26029837)

I've run the C-172M checklist several hundred times, and let me tell you, it's *very* easy to lose track of your place in the list, and forget whether your memory of having completed a given item is from this evening's flight, or from the one you did this morning.

That is a problem, but it's much less likely that you'll fall for it when you're working to the checklist, rather than trying to remember what you need to check also. 'Are the tyres OK? I'm sure they were'...

I've *never* caught a condition with my checklist that would have killed me, had I missed that item.

No, but does that mean you don't need to do it? I went through the checklist one time before a flight and discovered no fire extinguisher on board - I didn't need it, as it happens. But the reason it wasn't there was that the engine had caught fire the previous week, and they'd used it. You can be damn sure that guy was glad he checked for it! And there was no way I was starting the engine without it, either.

That said, it had been flown at least twice since then, and no-one else had spotted the missing extinguisher, despite it being on the checklist. If it hadn't been, would I have thought of it? I doubt it...

My personal experience leaves me wondering if it's possible that checklists could cause obvious things to be *missed*.

Sure - if the checklist doesn't say 'ensure wings are attached' someone will claim it's useless to have a checklist. We use checklists for software upgrades all the time (non-aviation), and it doesn't prevent errors, mistakes or other problems. It does however provide evidence that you checked, and prevents any number of issues from biting you.

I think part of the problem is that it provides a paper trail - if the patient dies, the first stop for the lawyers will be 'did they do everything on the list' and some doctors might be afraid that the existence of a checklist might incriminate them.

Pilots seem to cope OK though - and in emergencies are expected to know what to do, without a list. Doctors shouldn't be any different.

Mark

### Re:Look at Airplanes (5, Interesting)

#### Chapter80 (926879) | more than 5 years ago | (#26029989)

Your comment reminds me of a programming anecdote that I have told here before. We are responsible for a software package that coincidentally has patient data in it (but this applies to all sorts of applications).

The medical staff was supposed to log all interactions, which range from medicines administered to having a conversation with the patient or parent/guardian. Everything was to be logged, so that nothing was forgotten. And nothing could ever be deleted, by design.

Well, people made mistakes (the nerve of them!), and sometimes a record would be entered on the wrong patient, and you'd really WANT to delete that misleading information. This spawned numerous debates as to whether the we should really remove the erroneous information, or mark it as bad information. For instance, if Note 5 was that a certain drug was administered, and a Doctor relied on Note 5's misinformation to do whatever was done in Note 6, by deleting Note 5, you remove the defense and rationale of the Doctor.

Likewise, if you allow temporary removal of a note, then you allow someone to "undelete", you could end up in a similarly indefensible position. Note 5 correctly says that full dosage was administered at 10PM. Note 5 gets inadvertently deleted (recycle bin). At 10:05, a nurse sees that no dosage has been administered, so administers another full dosage, and logs it as Note 6. Someone undeletes Note 5, and makes the nurse look incompetent. Patient dies. Nurse got framed. All bad.

After all these discussions, at the direction of the administration, we built a permanent delete function, so that these erroneous notes could be permanently removed. No "recycle bin". Heavy logging of what transpired and when. And an alert window warning the user that they are about to perform an irreversible action of delete.

... and the "known data blindness" (or something like it) caused people to click through the warnings. How many Windows Alert boxes do users get per day, where they just press OK. Well, we kept getting requests to "undelete something that I just deleted", even though we warned them with a Windows Alert box.

So we made the warning bigger and longer and wordier. And the rate of calls to undelete something went UP.

Finally we changed the alert box to prompt the user to do something different. In order to complete the Delete function, the user had to key in the word "irreversible" into the alert prompt.

Requests to undelete went down to near-zero.

### That's why they call it a check list (2, Insightful)

#### FranTaylor (164577) | more than 5 years ago | (#26030051)

If you actually check off the items on the list and not just look at them, you don't need your memory to tell you whether you've done them or not, you can just look at the check marks.

The other half of the equation is taking the check list seriously in the first place. If you do that, then you WILL read and comprehend the questions.

### Re:That's why they call it a check list (1)

#### Antique Geekmeister (740220) | more than 5 years ago | (#26030275)

There's a little problem in an ICU: sometimes your hands are covered with things you really don't want to leave smeared on a checklist. This is where a nurse or doctor trading off on such tasks as needed can be a godsend. It's the perfect task for the new nurse on staff, who's learning the ropes.

### Look at Suction. (1)

#### Ostracus (1354233) | more than 5 years ago | (#26029273)

"Don't they already have some kinds of checklists for "make sure we don't leave any sponges or scalpels in the patient.""

Corsec67, I'm sorry to tell you but we left a nurse inside you.

### Re:Look at Suction. (1)

#### Ian Alexander (997430) | more than 5 years ago | (#26029317)

Sounds pretty kinky to me. What is this, Rocky Horror Hospital?

### Re:Look at Airplanes (1)

#### timeOday (582209) | more than 5 years ago | (#26029333)

The article goes a step further and talks about the specific event that gave rise to the checklist in aviation. (But I won't spoil it for you here!)

### Re:Look at Airplanes (1)

#### brarrr (99867) | more than 5 years ago | (#26029457)

please mod parent up under the RTFA Funny tag.. oh wait...

yes i know it was a way to long FA but it specifically brings up the introduction of checklists in aviation - specifically. ie a plane crashed and they figured the cause was that it was too complicated to fly so pilots should have checklists to prevent such problems.

### If you are a leftist like me: (0)

#### Anonymous Coward | more than 5 years ago | (#26029111)

then you must realize that that's at least 14,000 new homes destroying natural habitat. 28,000 extra people consuming resources and having too many kids.

Let them go. Save everybody and you damn everybody.

### Re:If you are a leftist like me: (2, Funny)

#### Bob Gelumph (715872) | more than 5 years ago | (#26029157)

Sure thing, Malthus.
I agree that the earth cannot possibly support more than a few million people, a hundred million absolute tops.

### Re:If you are a leftist like me: (0)

#### Anonymous Coward | more than 5 years ago | (#26029573)

28,000 people occupying 14,000 homes sounds like a community with NO kids.

If a fix for a problem isn't extremely expensive and convoluted with contracts for politicians friends, there will likely be no mandate for it, so short of lawsuits that start quoting these findings, probably nothing will happen, because there will be no coordination, in which case it will cost considerably more than $3M nationally, and regions will not be able to justify it. I say this extremely long statement with a bit of experience. I created an application for exactly this purpose to be used by a major hospital in the UK. My point is that it was just for the one hospital. There was no standardisation across the industry. The company I worked for at the time made websites and intranets for lots of hospitals, all basically the same thing, and each one costed and sold entirely separately. The hospital system could have paid 5 times the cost of one site and gotten hundreds, but that just wasn't how they did things. ### The numbers are off (1) #### syousef (465911) | more than 5 years ago | (#26029163) Pronovost oversaw the introduction of checklists in the ICUs in hospitals across Michigan, and the result was a thousand lives saved in a year. That would translate to 28,000 per year if scaled nationwide I know that the US medical system is in tatters but surely you have more than 28 large hospitals nationwide??? ### Re:The numbers are off (1) #### syousef (465911) | more than 5 years ago | (#26029175) Never mind I just saw my error. He didn't trial this in one hospital - he did so in a whole state (presumably one that has more hospitals than average since you have more than 28 states). ### Re:The numbers are off (1) #### afidel (530433) | more than 5 years ago | (#26029549) Not more hospitals than average, more ICU patients than average. Michigan has about 3% of the US population so based on the numbers in the article I have to assume they have a slightly lower than average number of ICU patients per capita. ### Re:The numbers are off (1) #### Lorens (597774) | more than 5 years ago | (#26029835) Going from a year-old memory, he did the trial in one ward, the the hospital, then a number of hospitals in the state (but not *all*, ISTR it was voluntary, or it was all the hospitals with XYZ insurance company since the insurance company backed him up) ### Re:The numbers are off (1, Informative) #### Anonymous Coward | more than 5 years ago | (#26029195) Michigan is a state, not a hospital.. I dont know US demographics that well, but it could be that Michigan has 1/28th of the total US population.. ### Re:The numbers are off (0) #### Anonymous Coward | more than 5 years ago | (#26029199) Pronovost oversaw the introduction of checklists in the ICUs in hospitals across Michigan, and the result was a thousand lives saved in a year. That would translate to 28,000 per year if scaled nationwide I know that the US medical system is in tatters but surely you have more than 28 large hospitals nationwide??? Yes, and there is more than one hospital in Michigan, as the statement you quoted makes abundantly clear. ### The checks in the mail. (2, Funny) #### Ostracus (1354233) | more than 5 years ago | (#26029197) "The article goes on to profile a doctor named Peter Pronovost, who has extensively studied the ability of the simplest of complexity tamers â" the checklist â" to save lives in the ICU setting." 1) Is patient alive? No check. 2) Search wallet. Check. ### Just another fad (0, Troll) #### dorpus (636554) | more than 5 years ago | (#26029207) So the checklist reduced infection rates. But then, how many lives were lost for other reasons because medical staff wasted time on these checklists, while nurses enjoyed obstructing physicians? A few years ago, people were absolutely sure that millions of lives could be saved by having AEDs everywhere. How many lives are being lost by amateur do-gooders who unnecessarily electrocute people who are not having heart attacks? Plenty of medical problems can appear like heart attacks to the untrained eye. ### Re:Just another fad (1, Informative) #### Anonymous Coward | more than 5 years ago | (#26029281) An AED will not send a jolt if it doesn't detect the correct electrical signal in the heart. That is what the A is for in AED. ### Re:Just another fad (1) #### evanbd (210358) | more than 5 years ago | (#26029481) When well implemented, checklists run very smoothly. If the list itself and the procedure for using it are well understood and familiar, the time cost is minimal and often negative -- you'll never have to stop and think for long about what needs to be done next, because as soon as you start to the person with the list will start reading the next step. More importantly, missed checklist steps result in substantial time losses in the future -- the reduced infection rates mentioned in the article don't just save lives, they reduce the amount of time spent dealing with infections. Good use of checklists is not something where the benefits marginally outweigh the costs. The benefits, in a medical context or elsewhere (my personal experience is with rocket engine testing), can *massively* outweigh the costs -- and frequently there simply aren't any costs you could reasonably chalk up to the use of the checklist aside form the time spent writing it in the first place (which is recouped very, very quickly). ### Re:Just another fad (1, Interesting) #### dorpus (636554) | more than 5 years ago | (#26029557) Let's compare apples to apples. What if you were in a rocket engine testing facility where dozens of rocket engines are simultaneously in danger of failing, and all the rocket engines had to keep running at all costs? Would you want to go through the formality of checklists? If ICU patient #37 died while doctors were going through the checklist for patient #14, won't the media headlines scream that "ICU patients die while doctors are held up by hospital bureacracy"? There is an interesting recent article that shows how fire extinguishers are harmful to public health; 4% of fire deaths each year are caused by amateur operators who attempt to extinguish flames with their "mandatory" fire extinguishers. As the paper states, "As described above, in terms of life safety (as opposed to preventing material losses), attempting to extinguish a fire is not effective. For a fire extinguisher to work, a fire must be small, accessible, and not producing large quantities of smoke. In the face of such a fire, the safest course of action is to evacuate the area.... Fire extinguishers require extensive training to be used effectively. Using a fire extinguisher exposes the operator to physical danger and in terms of life safety--evacuation, as opposed to attempting to extinguish the fire probably represents the best option." Mass hysteria has mandated "safety" laws before, which have turned out to do more harm than good in the long run. Prog Cardiovasc Dis. 2008 Nov-Dec;51(3):204-12. ### Re:Just another fad (2, Insightful) #### evanbd (210358) | more than 5 years ago | (#26029649) How many of those fire extinguisher deaths are caused by *untrained* operators? I would guess all of them. You don't have untrained operators working in an ICU or at a rocket test site. The more critical the rocket test, and the more chaotic the environment, the more important checklists become. I'm sure the same is true in an ICU. The idea that checklists slow down complex operations is, quite simply, wrong. They usually have a negligible impact on speed, and can often speed things up. Frequently the order on the checklist was chosen for efficiency -- doing things out of order works, and is equally intuitive, but slower. You spend less time thinking about what to do next. You never stop to wonder whether you remembered to do a step, and then wasting time going back to check a setting. I would *not* advocate making such things legally mandatory -- there's simply too much inertia to laws, and they're likely to be either so vague they're useless or so detailed they interfere. However, having the people involved write and use checklists for the things they're doing becomes very important as the complexity rises. Part of the benefit of checklists is that you can pause things. If patient 37 needs a bunch of things done, but none of them have to get done *right* *now*, and then patient 14 develops an emergency, you can put down the checklist and rush to the other patient. After the emergency, you return -- and you're far less likely to forget a step or repeat a step, since the nurse was checking them off while the doctor did them. You can't be a slave to a checklist any more than you can assume any other tool is always appropriate. Part of the job of the skilled operator is to know when to ignore the checklist. Decisions to ignore the checklist should *always* be conscious decisions, not forgetfullness. ### Re:Just another fad (1) #### evilad (87480) | more than 5 years ago | (#26030249) Imagine that most of the time, the "failure" isn't catastrophic (ie, patient death), but rather a failure of the test itself, merely requiring the engine to spend more time (ie, prolonged ICU stay) in retesting. The reduction in failures due to checklists will obviously cause a reduction in total time spent testing, causing a *reduction* in workload. The question of which checklists are useful could then be reduced to a very simple economics problem, involving initial failure rate, time spent per checklist, failures prevented, and time saved per avoided failure. It might also be worthwhile to assign a bonus of five or ten minutes per catastrophic failure averted. Under some circumstances, saved lives do have a non-zero value. ### 1% is actually quite awful (3, Insightful) #### syousef (465911) | more than 5 years ago | (#26029223) Imagine if the brakes on your car failed just 1% of the time. For every 100 times you brake 1 time you'd just keep going. How many times do you brake on an average 1 hour trip? Sometimes for mission critical systems even 99.999% isn't good enough. It's not just mission critical systems though. What about computers. If they made errors once in 10000, with several billion cycles per second, they'd be unusable. Anyway if each patient requires 178 actions then 1% means every patient has between 1 and 2 mistakes made for them per day. I presume some of these actions are trivial otherwise I'd be amazed if anyone survived. ### Re:1% is actually quite awful (0) #### Anonymous Coward | more than 5 years ago | (#26029349) But we're not talking about machines, we're talking about people. People can and will make mistakes, and a rate of 1% is actually quite low. ### Re:1% is actually quite awful (1) ####$random_var (919061) | more than 5 years ago | (#26029553)

In particular, we're talking about people independently and coordinatedly reacting to a wide variety of complex circumstances with complex actions. 1% is damn impressive considering the processes for making those decisions and taking those actions. But the GP is right - it's not enough. That's the point of the article; if we can use checklists to improve on that 1%, we'll be a lot better off.

### Re:1% is actually quite awful (3, Insightful)

#### NIckGorton (974753) | more than 5 years ago | (#26029391)

Imagine if the brakes on your car failed just 1% of the time. For every 100 times you brake 1 time you'd just keep going. How many times do you brake on an average 1 hour trip? Sometimes for mission critical systems even 99.999% isn't good enough. It's not just mission critical systems though. What about computers. If they made errors once in 10000, with several billion cycles per second, they'd be unusable.

You are comparing apples to... well not even oranges... to manhole covers. With a computer or a mechanical device it is possible to ensure that failures don't happen 99.999% of the time. With human beings taking actions that is much less reasonable.

Though if you think that is possible, go an entire day without making one single mistake. No misplacing your keys. No forgetting the milk at the store. No traffic tickets. No wrong turns while driving. No spelling mistakes while you are typing. No truthfulness when your girlfriend asks you if she looks fat in this dress. Not. One. Single. Mistake.

Of course one might argue that if something important like a life is on the line, people should be much more careful than they are while shopping or typing a reply on /. That is a reasonable question, but again as soon as there are no more motorcycle accidents, no more drunk drivers, and Vista is taken off the market we can then expect a human being to do any task with 99.9999% perfection.

### Re:1% is actually quite awful (2)

#### syousef (465911) | more than 5 years ago | (#26029441)

Though if you think that is possible, go an entire day without making one single mistake.

Oh for pity sake. I'm not suggesting we create infalible human beings or require human beings to be infallible. It is possible to ensure people do things much more accurately through a system of redundancy. More than one person checking off on a procedure (when time permits). More checks and balances. Automation of arithmetic for calculating dosages. Automation in diagnostics so that a doctor can check he hasn't missed a possible cause for a condition etc.

Also differentiate between petty stuff that will mean a patient is inconvenienced and stuff that will kill a patient.

More than 99% of plane landings go well. Your odds of surviving when you drive to work are better than 99%. It IS possible.

### Re:1% is actually quite awful (0)

#### Anonymous Coward | more than 5 years ago | (#26029503)

Man, you have all the answers.

### Re:1% is actually quite awful (1)

#### NIckGorton (974753) | more than 5 years ago | (#26029599)

It is possible to ensure people do things much more accurately through a system of redundancy. More than one person checking off on a procedure (when time permits). More checks and balances. Automation of arithmetic for calculating dosages. Automation in diagnostics so that a doctor can check he hasn't missed a possible cause for a condition etc.

Great. And your health care costs will rise commensurately.

Though I have no idea what you mean with regards to automation in diagnostics? How the heck do you suggest that this happen given that diagnosis is largely a directed interview with a person augmented by a few elements of the physical exam and sometimes a few lab or imaging studies? I would love the medical Tricorder that they have on Star Trek, but as yet I haven't found that ap for my GPhone.

Also differentiate between petty stuff that will mean a patient is inconvenienced and stuff that will kill a patient.

And that is easy to work out retrospectively. Not so much prospectively. Getting your turkey sandwich with cheese, tomato, and a side of OJ can kill a dialysis patient. So is delivering the right tray to Ms Smith in 201B rather than Ms Jones in 202B a 'big thing' or a 'petty thing'?

### Re:1% is actually quite awful (1)

#### syousef (465911) | more than 5 years ago | (#26029765)

Great. And your health care costs will rise commensurately.

Yes, because industries that have been able to automate have had their prices skyrocket. Like the car industry. Nope. Or the toy industry. Nope. Food manufacture. Um, nope. Mining? Nope.

Though I have no idea what you mean with regards to automation in diagnostics? How the heck do you suggest that this happen given that diagnosis is largely a directed interview with a person augmented by a few elements of the physical exam and sometimes a few lab or imaging studies?

I'm talking about expert systems. Not the kind that try to replace a doctor. The kind that asks a few questions and suggests some possible diseases that fit most of the symptoms. If a doctor had guessed similar to the expert system, excellent, he can be confident he's on the right track. If some of the suggestions are rarer or not on the doctor's radar, it's one more thing to consider if they wish to.

I would love the medical Tricorder that they have on Star Trek, but as yet I haven't found that ap for my GPhone.

Funny I thought you were more interested in having a toxic tone and being filled with bile and irony.

And that is easy to work out retrospectively. Not so much prospectively. Getting your turkey sandwich with cheese, tomato, and a side of OJ can kill a dialysis patient. So is delivering the right tray to Ms Smith in 201B rather than Ms Jones in 202B a 'big thing' or a 'petty thing'?

It's a matter of context. There are lots of situations in which diet are critical for a patient. My wife has an anaphylactic reaction to food and you should see the hoops she has to jump through to to the dieticians in hospital that she would rather I supplied her food because they're likely to get it wrong and kill her. (We're not talking about simply avoiding nut products here. Her food allergies are complex and difficult to manage)

So diet in a patient marked with special dietary needs is NOT a petty thing, but for many patients it is. This is true of anything put into a patient's body which is why a patient with allergies gets a nice red wrist band to warn the nurse.

Again the real world may not be simple but it CAN be managed. A defeatist attitude and a ton of sarcasm do NOT help.

### Re:1% is actually quite awful (0)

#### Anonymous Coward | more than 5 years ago | (#26029497)

Yeah, but doctors are paid metric assloads of money to not make mistakes at least the mistakes that can cost someone their life.

I still think they should pass a law that says a doctor can charge whatever they want, but if the treatment fails, they have to provide a full refund. (maybe up to 20x refund if the failure was due to negligence)

Maybe that would cut down on the health care industries practice of offering costly experimental treatments as a "guaranteed cure" to the desperate and dying.

#### Anonymous Coward | more than 5 years ago | (#26029397)

So based on the math, the cost of a person's life is worth $107.$3,000,000/28,000

Thats assuming that the $3,000,000 is required each year. Sounds like another reason to be pissed at the medical industry if they don't do it now that they're aware. Makes me curious if the cost of medical malpractice suits are higher than this$3,000,000.

### Re:Cost of a life = $107 (1) #### Renraku (518261) | more than 5 years ago | (#26029461) You're wrong, however. A life is only worth as much as someone else is willing to pay to preserve it. If no one will pay for your life saving operation, your life wasn't worth the cost of said operation, apparently. People die every day from lack of money. Either through starvation, lack of medicine, or lack of surgery. Its sad, but this is what humanity must do until everyone has food/supplies/shelter given to them for free, and can actually donate their time without having to keep a real job just to keep some food on the table and a roof over their heads. ### Personal anecdote - it works! (4, Interesting) #### bertok (226922) | more than 5 years ago | (#26029511) Checklists certainly aren't just for medicine, they work great in IT too. As a system integrator / contractor, I've found that lots of IT people have a somewhat.. haphazard approach to day-to-day tasks like building servers or provisioning users. This inevitably leads to mistakes and forgotten steps, which then results in angry users and system failures. Of course, the same IT people then apply the fix with the same lax methodology, and the result is yet another failure, and an even angrier user. I've seen this cycle repeat as often as 3 or 4 times, until managers get involved, and fingers are pointed. It's very unpleasant for everyone after that. My method is trivially simple, and required nothing other than a text editor, even Notepad works fine, but a more robust editor is even better. I call it: "Pete's Patented TODO List System". (Patent not pending). Simply open a new file, and create a line for every single step of the task you're about to do, even if it's blindingly obvious. Prefix each step with a pair of square braces as a placeholder for a check box. E.g.: === BUILD SERVER === [o] Back up existing data from drives [.] Patch BIOS to latest version [ ] Reset BIOS settings to platform defaults [ ] Boot installer from \\foo\bar\... [ ] Configure drives [ ] Clean existing RAID [ ] Create mirror pair [ ] Configure block size to 64KB ... Once you have the file, as you build the server, you tick steps off by filling in the checkboxes. E.g.: [ ] Not done [.] Started / partially done [o] Done. [!] Issue / problem [?] May not need doing / optional / ask [-] Cancelled / no need. So you ask.. why is "Pete's Patented TODO List System" so awesome? Because it works, it's free, and it's flexible. I found my error rate plummeted, and I could then email the list to someone else, and they could reproduce a successful procedure flawlessly by simply following the steps. There's actually a whole range of reasons why a text-based TODO list system is the best for IT: - It can be cut & pasted back and forth between local and remote systems. - After a task is complete, you can email it to managers or coworkers as a "record of activity". - Others can read your list without requiring a client such as Microsoft Project. - Any idiot can use a text editor without special training. Quickly reorganising the structure and order of a complex multi-step task in dedicated Project management software takes effort, and may cumbersome. - It's easy to cut & paste parameters, values, scripts and command in and out of the TODO file. - You can reset a file to "blank" by doing this Regex search and replace: $.$ => [ ] - Did I mention it's free? (I do accept PayPal donations, however) In general, TODO lists rock, especially in environments where scripting everything is not practical. For example, if you build multiple servers in parallel, simply open two Notepad windows, and track the progress of each server. If you're interrupted by a phone call or a user, you WILL forget what exactly you have or haven't done, and that's when fuckups occur. Not to mention that most IT people just don't do "all the steps", which is one of the main points in the article. For example, do you, or the people working with you, do ALL of the following when configuring a server: - Wipe all of the existing configuration, including BIOS settings? - Run a memory check? - Set the date and time in the BIOS? - Patch up all components to the correct / latest levels, including obscure things like the network card firmware? - Install, configure, and TEST the antivirus, backup, and monitoring modules? Did you run a test backup AND a test restore? - Verify that every step worked? If the answer is no to ANY of those, you or your people are fucking up on a regular basis, whether you know it or not. I've lost count of the number of times I've seen "enterprise clusters" where 2 of the 5 nodes have a different date & time. It's a trivial thing, yes, but MY GOD DOES IT BREAK THINGS if you forget. ### Absolutely!!! (1) #### FranTaylor (164577) | more than 5 years ago | (#26030089) Awesome!!! I have my entire server provisioning procedure in a single shell script. I run the installer, update everything, and then run my "magic" shell script. When it's done, the system is ready for action. I think of the shell script as a TODO list, but it's bash that's doing the work instead of me. I wouldn't have it any other way. Human memory is too fallible, and even written instructions are open to interpretation. ### Re:Personal anecdote - it works! (1) #### maidix (803080) | more than 5 years ago | (#26030391) This makes way more sense than any of the bloated "project management" softwares I've been reviewing lately, all of which seem to require more management themselves than said projects. I've been using text-based TDLs for a while, and I think you've got a great method for organizing a lot of relevant data in an intuitive & flexible way. ### A practical cost-effective idea! (0) #### Anonymous Coward | more than 5 years ago | (#26029571) Quick! Somebody call Barack Obama! ### WTF? This article is a year old. (1) #### numbsafari (139135) | more than 5 years ago | (#26029585) Umm... I don't know if the editor noticed, but this article was published over a year ago. How is this news? ### Re:WTF? This article is a year old. (1) #### Chapter80 (926879) | more than 5 years ago | (#26030025) Umm... I don't know if the editor noticed, but this article was published over a year ago. How is this news? Bigger news! 28,000 more people died! ### This is harder than it sounds (1, Insightful) #### Anonymous Coward | more than 5 years ago | (#26029595) People can be quite resistant to things like checklists, thinking they know it already. Checklists will help with procedures that are rare enough that people will know to revert to the checklist, but I bet relatively common activities will still be subject to errors. dom ### RTFA Re:This is harder than it sounds (1) #### Lorens (597774) | more than 5 years ago | (#26029947) He assigned an extra nurse to make sure that the others followed the checklist. At first the nurse was just an observer, but when the trial period results revealed serious omissions in some incredibly high percentage of cases (ISTR 33%), the nurses were authorized to intervene and tell the doctor to respect the procedure. ### The actual paper (4, Informative) #### argiedot (1035754) | more than 5 years ago | (#26029597) You can find the actual paper in the New England Journal of Medicine [nejm.org] . I think many here are missing the point. Peter Pronovost's suggestion to use a checklist is to ensure that commonly done tasks are done properly, not that a surgeon will have to look at a piece of paper before he moves each vein aside. And, as he has demonstrated, it works. It's not as glamorous as discovering a cure for some new disease, but it works great. Notice the other things mentioned in the New Yorker article: • Nurses were authorised by the hospital administration to correct doctors when they skipped part of a procedure. • Mundane processes were pushed to a checklist, so recalling them was no longer a human task, letting the doctors focus on the parts that actually require them to think. In fact, the most important part of the whole article is in these paragraph: First, they helped with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic events. (When you're worrying about what treatment to give a woman who won't stop seizing, it's hard to remember to make sure that the head of her bed is in the right position.) A second effect was to make explicit the minimum, expected steps in complex processes. Pronovost was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions. In a survey of I.C.U. staff taken before introducing the ventilator checklists, he found that half hadn't realized that there was evidence strongly supporting giving ventilated patients antacid medication. Checklists established a higher standard of baseline performance. ### This is a year old, but (2, Informative) #### Lorens (597774) | more than 5 years ago | (#26029799) But if it isn't being done yet, a reminder won't do any harm! The most significant thing I find (going from a year-old memory) is that they had to get the bean-counters to increase the amounts of disinfectant and protection sheets they bought, since these amounts increased VERY significantly when check-lists were used! ### Collecting and passing information is the problem (2, Informative) #### Anonymous Coward | more than 5 years ago | (#26029809) Last year unfortunate circumstances gave me a first hand view of the issues surrounding hospital care and I suggest they work on the collection of patient details and record of care. It was aggravating! Every time some new specialist or attending nurse was introduced to my wife's case, or when she was moved from observation, to surgery, to immediate care, to intensive care, each step along the way, no one got the details straight!!! Argh! Each time the hand off was done mostly verbal, always asking the same basic questions time and again, and if they forgot to ask a question of the outgoing staff, they would interrogate my wife who was heavily sedated and mostly unaware of her surroundings. Each time I had to step in and clarify. We were lucky she had a seasoned doctor, and I personally witnessed him rip a few new a$$holes. I had the same thing happen when I slipped a disk in my lower back and required an ambulance. Although in excruciating pain, I had to recite my history and present circumstances to each staff member I came in contact with. It was like watching the old telephone game, where the original spoken message to the first person rarely matches by the time it makes it to the last person. If they just had a way to not only capture the patient background and case history but easily convey it to next nurse or doctor, I would bet it would reduce plenty of mistakes. Currently, the details are written on forms, then entered into computers, only to be requested again from the patient by the doctor or next specialist or consultant. It would seem they either don't have easy or convenient access to the data on the computer or the doctors don't have the time to read the narrative. Perhaps some form of speech synthesis would work. The doctor could step into the room, press a button and get the playback or some form of timeline with the ability to drill down into details. On a final note, if you ever have someone you know in the hospital, never leave them alone. You should make every effort to oversee their care and babysit the doctors and nurses. I don't know if our case was indicative, but when I saw my wife, who was hanging on to life in the ICU, sit up and scream because the nurse attempted to reuse an expired IV point, it got my attention! Not two minutes early I just got done telling her that the reason they moved her from immediate care to intensive care was because they could no longer medicate her through her IVs since they had all expired. Fortunately she pulled through and has little memory of the hospital events. By the way, I almost lost her and it was just a kidney stone that was stuck. Don't ever buy the line "oh, they are painful but they will just pass". If the stone backs up the kidney too long, it can create an infection, which will immediately pass into the bloodstream. The rest is pretty fast and scary. ### Article was published A YEAR AGO (2007) (0) #### Anonymous Coward | more than 5 years ago | (#26030161) What's up? The article this piece references was published in the Dec 7, 2007 edition of the New Yorker. It's a great article and I enjoy the discussion of it, anytime -- but this kind of violates my expectations of Slashdot content and that's problematic. ### Checklist has problems though (2, Interesting) #### Secret Rabbit (914973) | more than 5 years ago | (#26030255) Namely, being that once a check-list is created, after a while, one gets to the point where it's only the check-list that matters. Not on the check-list, doesn't happen. In other words, it allows people to get lazy and not pay attention. So, there will likely be errors produced from that negating the lives saved with nothing gained, but at the same time, a grand potential lose. The lose being a mentality of brainlessness in the ICU. One must weight also weigh the practical consequences of such things that would have benefits against those benefits as well. We need to see a net gain first. Especially before widespread adoption. ### First time that my girlfriend receives an NEJM... (0) #### Anonymous Coward | more than 5 years ago | (#26030301) First time that my girlfriend shall receive a NEJM (New England Journal of Medicine) that had an article on /. She's a recent subscriber to the NEJM and her day (and night) work, as a doctor working in an ICU, is a lot about placing catheter. This is going to make for an interesting discussion tonight when she comes back :) ### Yet more paperwork... (0) #### Anonymous Coward | more than 5 years ago | (#26030365) As an RN, I can say that paperwork has gotten totally out of control. Most of my time is spent documenting stuff, rather then simply spending time with the patients. IMO what improves patient care/quality is spending more time with patients. I would be very weary of any additional mandatory documentation, especially if it is in paper form. I would be OK with the checklist idea if it took the place of other paperwork instead of being a new item. They could even put the checklist into a PDA application, which could then automatically document what was done in the chart. We already use PDAs at my hospital for meds and other things. ### Save a few billion (1) #### tshetter (854143) | more than 5 years ago | (#26030371) Submitter/kdawson should have kept going with the summary... FTFJA: Important reductions in morbidity and health care costs could be achieved if the intervention to reduce catheter-related bloodstream infections could be introduced successfully nationwide or worldwide. Given the results of the study, many of the estimated 80,000 infections, up to 28,000 deaths, and$2.3 billion in costs attributed to these infections annually in the United States could be reduced.

Spend $3 million to save$2.3 billion, JUST on catheter-related bloodstream infections in the US each year.

Stunning.
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