The Checklist Manifesto
Page 18
39 "This reduced from 41 percent": M. A. Erdek and P. J. Pronovost, "Improvement of Assessment and Treatment of Pain in the Critically Ill," International Journal for Quality Improvement in Healthcare 16 (2004): 59-64.
39 "The proportion of patients": S. M. Berenholtz et al., "Improving Care for the Ventilated Patient," Joint Commission Journal on Quality and Safety 4 (2004): 195-204.
39 "The researchers found": P. J. Pronovost et al., "Improving Communication in the ICU Using Daily Goals," Journal of Critical Care 18 (2003): 71-75.
39 "In a survey of ICU staff": Berenholtz et al., "Improving Care."
41 "But between 2000 and 2003": K. Norris, "DMC Ends 2004 in the Black, but Storm Clouds Linger," Detroit Free Press, March 30, 2005.
44 "In December 2006": P. J. Pronovost et al., "An Intervention to Reduce Catheter-Related Bloodstream Infections in the ICU," New England Journal of Medicine 355 (2006): 2725-32.
3. THE END OF THE MASTER BUILDER
48 "Two professors who study": S. Glouberman and B. Zimmerman, "Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like?" discussion paper no. 8, Commission on the Future of Health Care in Canada, Saskatoon, 2002.
54 "His firm, McNamara/Salvia": Portfolio at www.mcsal.com.
59 "We've been slow to adapt": Data from the Dartmouth Atlas of Health Care, www.darmouthatlas.org.
69 "It was planned to rise": R. J. McNamara, "Robert J. McNamara, SE, FASCE," Structural Design of Tall and Special Buildings 17 (2008): 493-512.
70 "But, as a New Yorker story": Joe Morgenstern, "The Fifty-Nine-Story Crisis," New Yorker, May 29, 1995.
71 "In the United States": U.S. Census data for 2003 and 2008, www.census.gov; K. Wardhana and F. C. Hadipriono, "Study of Recent Building Failures in the United States," Journal of Performance of Constructed Facilities 17 (2003): 151-58.
4. THE IDEA
73 "At 6:00 a.m.": Hurricane Katrina events and data from E. Scott, "Hurricane Katrina," Managing Crises: Responses to Large-Scale Emergencies, ed. A. M. Howitt and H. B. Leonard (Washington, D.C.: CQ Press, 2009), pp. 13-74.
76 "Of all organizations": Wal-Mart events and data from S. Rose -grant, "Wal-Mart's Response to Hurricane Katrina," Managing Crises, pp. 379-406.
78 "For every Wal-Mart": D. Gross, "What FEMA Could Learn from Wal-Mart: Less Than You Think," Slate, Sept. 23, 2005, http://www.slate.com/id/2126832.
78 "In the early days": Scott, "Hurricane Katrina," p. 49.
80 "As Roth explained": D. L. Roth, Crazy from the Heat (New York: Hyperion, 1997).
81 "Her focus is on regional Italian cuisine": J. Adams and K. Rivard, In the Hands of a Chef: Cooking with Jody Adams of Rialto Restaurant (New York: William Morrow, 2002).
5. THE FIRST TRY
87 "By 2004": T. G. Weiser et al., "An Estimation of the Global Volume of Surgery: A Modelling Strategy Based on Available Data," Lancet 372 (2008): 139-44.
87 "Although most of the time": A. A. Gawande et al., "The Incidence and Nature of Surgical Adverse Events in Colorado and Utah in 1992," Surgery 126 (1999): 66-75.
87 "Worldwide, at least seven million people": Weiser, "An Estimation," and World Health Organization, World Health Report, 2004 (Geneva: WHO, 2004). See annex, table 2.
91 "The strategy has shown results": P. K. Lindenauer et al., "Public Reporting and Pay for Performance in Hospital Quality Improvement," New England Journal of Medicine 356 (2007): 486-96.
93 "When the disease struck": S. Johnson, The Ghost Map (New York: Riverhead, 2006).
95 "Luby and his team reported": S. P. Luby et al., "Effect of Hand-washing on Child Health: A Randomised Controlled Trial," Lancet 366 (2005): 225-33.
98 "But give it on time": A. A. Gawande and T. G. Weiser, eds., World Health Organization Guidelines for Safe Surgery (Geneva: WHO, 2008).
102 "In one survey of three hundred": M. A. Makary et al., "Operating Room Briefings and Wrong-Site Surgery," Journal of the American College of Surgeons 204 (2007): 236-43.
102 "surveyed more than a thousand": J. B. Sexton, E. J. Thomas, and R. L. Helmsreich, "Error, Stress, and Teamwork in Medicine and Aviation," British Medical Journal 320 (2000): 745-49.
108 "The researchers learned": See preliminary data reported in "Team Communication in Safety," OR Manager 19, no. 12 (2003): 3.
109 "After three months": Makary et al., "Operating Room Briefings and Wrong-Site Surgery."
109 "At the Kaiser hospitals": " 'Preflight Checklist' Builds Safety Culture, Reduces Nurse Turnover," OR Manager 19, no. 12 (2003): 1-4.
109 "At Toronto": L. Lingard et al. "Getting Teams to Talk: Development and Prior Implementation of a Checklist to Promote Interpersonal Communication in the OR," Quality and Safety in Health Care 14 (2005): 340-46.
6. THE CHECKLIST FACTORY
114 "Among the articles I found": D. J. Boorman, "Reducing Flight Crew Errors and Minimizing New Error Modes with Electronic Checklists," Proceedings of the International Conference on Human-Computer Interaction in Aeronautics (Toulouse: Editions Cepaudes, 2000), pp. 57-63; D. J. Boorman, "Today's Electronic Checklists Reduce Likelihood of Crew Errors and Help Prevent Mishaps," ICAO Journal 56 (2001): 17-20.
116 "An electrical short": National Traffic Safety Board, "Aircraft Accident Report: Explosive Decompression--Loss of Cargo Door in Flight, United Airlines Flight 811, Boeing 747-122, N4713U, Honolulu, Hawaii, February 24, 1989," Washington D.C., March 18, 1992.
116 "The plane was climbing": S. White, "Twenty-Six Minutes of Terror," Flight Safety Australia, Nov.-Dec. 1999, pp. 40-42.
120 "They can help experts": A. Degani and E. L. Wiener, "Human Factors of Flight-Deck Checklists: The Normal Checklist," NASA Contractor Report 177549, Ames Research Center, May 1990.
121 "Some have been found confusing": Aviation Safety Reporting System, "ASRS Database Report Set: Checklist Incidents," 2009.
129 "Crash investigators with Britain's": Air Accidents Investigation Branch, "AAIB Interim Report: Accident to Boeing 777-236ER, G-YMMM, at London Heathrow Airport on 17 January 2008," Department of Transport, London, Sept. 2008.
129 " 'It was just yards above' ": M. Fricker, "Gordon Brown Just 25 Feet from Death in Heathrow Crash," Daily Mirror, Jan. 18, 2008.
129 "The nose wheels collapsed": Air Accidents Investigation Branch, "AAIB Bulletin S1/2008," Department of Transport, London, Feb. 2008.
130 "Their initial reports": Air Accidents Investigation Branch, "AAIB Bulletin S1/2008"; Air Accidents Investigation Branch, "AAIB Bulletin S3/2008," Department of Transport, London, May 2008.
132 "Nonetheless, the investigators tested": Air Accidents Investigation Branch, "AAIB Interim Report."
132 "So in September 2008": Federal Aviation Administration, Airworthiness Directive; Boeing Model 777-200 and -300 Series Airplanes Equipped with Rolls-Royce Model RB211-TRENT 800 Series Engines, Washington, D.C., Sept. 12, 2008.
133 "One study in medicine": E. A. Balas and S. A. Boren, "Managing Clinical Knowledge for Health Care Improvement," Yearbook of Medical Informatics (2000): 65-70.
133 "almost 700,000 medical journal articles": National Library of Medicine, "Key Medline Indicators," Nov. 12, 2008, accessed at www.nlm.nih.gov/bsd/bsd_key.html.
134 "This time it was": National Transportation Safety Board, "Safety Recommendations A-09-17-18," Washington, D.C., March 11, 2009.
7. THE TEST
139 "Of the tens of millions": Joint Commission, Sentinel Event Alert, June 24, 2003.
139 "By comparison, some 300,000": R. D. Scott, "The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention," Centers for Disease Control, March 2009.
140 "The final WHO safe surgery checklist": The checklist can be accessed at www.who.int/safesurgery.
146 "We gave them some PowerPoint slides": The videos can be viewed at www.safesurg.org/materials.html.
156 "In January 2009": A. B. Haynes et al., "A Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Population," New England Journal of Medicine 360 (2009): 491-99.
8. THE HERO IN THE AGE OF CHECKLISTS
161 "Tom Wolfe's The Right Stuff": T. Wolfe, The Right Stuff (New York: Farrar, Straus and Giroux, 1979).
163 "Neuroscientists have found": H. Breiter et al., "Functional Imaging of Neural Responses to Expectancy and Experience of Monetary Gains and Losses," Neuron 30 (2001): 619-39.
166 " 'Cort's earning power' ": Wesco Financial Corporation, Securities and Exchange Commission, Form 8-K filing, May 4, 2005.
170 "Smart specifically studied": G. H. Smart, "Management Assessment Methods in Venture Capital: An Empirical Analysis of Human Capital Valuation," Journal of Private Equity 2, no. 3 (1999): 29-45.
172 "He has since gone on": G. H. Smart and R. Street, Who: The A Method for Hiring (New York: Ballantine, 2008).
173 "A National Transportation Safety Board official": J. Olshan and I. Livingston, "Quiet Air Hero Is Captain America," New York Post, Jan. 17, 2009.
174 "As Sullenberger kept saying": M. Phillips, "Sully, Flight 1549 Crew Receive Keys to New York City," The Middle Seat, blog, Wall Street Journal, Feb. 9, 2009, http://blogs.wsj.com/middleseat/2009/02/09/.
174 " 'That was so long ago' ": "Sully's Tale," Air & Space, Feb. 18, 2009.
178 "Once that happened": C. Sullenberger and J. Zaslow, Highest Duty: My Search for What Really Matters (New York: William Morrow, 2009).
179 "Skiles managed to complete": Testimony of Captain Terry Lutz, Experimental Test pilot, Engineering Flight Operations, Airbus, National Transportation Safety Board, "Public Hearing in the Matter of the Landing of US Air Flight 1549 in the Hudson River, Weehawken, New Jersey, January 15, 2009," June 10, 2009.
180 " 'Flaps out?' ": D. P. Brazy, "Group Chairman's Factual Report of Investigation: Cockpit Voice Recorder DCA09MA026," National Transportation Safety Board, April 22, 2009.
180 "For, as journalist and pilot": W. Langewiesche, "Anatomy of a Miracle," Vanity Fair, June 2009.
181 "After the plane landed": Testimony of Captain Chesley Sullenberger, A320 Captain, US Airways, National Transportation Safety Board, Public Hearing, June 9, 2009.
ACKNOWLEDGMENTS
Three kinds of people were pivotal to this book: the ones behind the writing, the ones behind the ideas, and the ones who made both possible. As the book involved background research in several fields beyond my expertise, the number of people I am indebted to is especially large. But this book could never have been completed without all of them.
First are those who helped me take my loose observations about failure and checklists and bring them together in book form. My agent, Tina Bennett, saw the possibilities right away and championed the book from the moment I first told her about my burgeoning fascination with checklists. My editor at the New Yorker, the indispensable Henry Finder, showed me how to give my initial draft more structure and my thinking more coherence. Laura Schoenherr, my brilliant and indefatigable research assistant, found almost every source here, checked my facts, provided suggestions, and kept me honest. Roslyn Schloss provided meticulous copyediting and a vital final review. At Metropolitan Books, Riva Hocherman went through the text with inspired intelligence and gave crucial advice at every stage of the book's development. Most of all, I leaned on Sara Bershtel, Metropolitan's publisher, with whom I've worked for nearly a decade now. Smart, tough, and tireless, she combed through multiple drafts, got me to sharpen every section, and saved me from numerous errors of tone and thinking, all the while shepherding the book through production with almost alarming efficiency.
As for the underlying ideas and the stories and experience fleshing them out, I have many, many to thank. Donald Berwick taught me the science of systems improvement and opened my eyes to the possibilities of checklists in medicine. Peter Pronovost provided a crucial source of ideas with his seminal work in ICUs. Lucian Leape, David Bates, and Berwick were the ones to suggest my name to the World Health Organization. Sir Liam Donaldson, the chair of WHO Patient Safety, who established the organization's global campaign to reduce deaths in surgery, was kind enough to bring me aboard to lead it and then showed me what leadership in public health really meant. Pauline Philip, the executive director of WHO Patient Safety, didn't take no for an answer from me and proved extraordinary in both her dedication and her effectiveness in carrying out work that has now extended across dozens of countries.
At WHO, Margaret Chan, the director general, as well as Ian Smith, her adviser, David Heymann, deputy director general, and Tim Evans, assistant director general, have all been stalwart supporters. I am also particularly grateful to Gerald Dziekan, whom I have worked with almost daily for the past three years, and also Vivienne Allan, Hilary Coates, Armorel Duncan, Helen Hughes, Sooyeon Hwang, Angela Lashoher, Claire Lemer, Agnes Leotsakos, Pat Martin, Douglas Noble, Kristine Stave, Fiona Stewart-Mills, and Julie Storr.
At Boeing, Daniel Boorman emerged as an essential partner in work that has now extended to designing, testing, and implementing clinical checklists for safe childbirth, control of diarrheal infections, operating room crises, management of patients with H1N1 influenza, and other areas. Jamie and Christopher Cooper-Hohn, Roman Emmanuel, Mala Gaonkar and Oliver Haarmann, David Greenspan, and Yen and Eeling Liow were early and vital backers.
At the Harvard School of Public Health, the trio of William Berry, Tom Weiser, and Alex Haynes have been the steel columns of the surgery checklist work. The WHO Safe Surgery program I describe in this book also depended on Abdel-Hadi Breizat, Lord Ara Darzi, E. Patchen Dellinger, Teodoro Herbosa, Sidhir Joseph, Pascience Kibatala, Marie Lapitan, Alan Merry, Krishna Moorthy, Richard Reznick, and Bryce Taylor, the principal investigators at our eight study sites around the world; Bruce Barraclough, Martin Makary, Didier Pittet, and Iskander Sayek, the leaders of our scientific advisory group, as well as the many participants in the WHO Safe Surgery Saves Lives study group; Martin Fletcher and Lord Naren Patel at the National Patient Safety Agency in the U.K.; Alex Arriaga, Angela Bader, Kelly Bernier, Bridget Craig, Priya Desai, Rachel Dyer, Lizzie Edmondson, Luke Funk, Stuart Lipsitz, Scott Regenbogen, and my colleagues at the Brigham and Women's Center for Surgery and Public Health; and the MacArthur Foundation.
I am deeply indebted to the many experts named throughout the book whose generosity and forbearance helped me explore their fields. Unnamed here are Jonathan Katz, who opened the door to the world of skyscraper building; Dutch Leonard and Arnold Howitt, who explained Hurricane Katrina to me; Nuno Alvez and Andrew Hebert, Rialto's sous chefs, who let me invade their kitchen; Eugene Hill, who sent me the work of Geoff Smart; and Marcus Semel, the research fellow in my group who analyzed the data from Harvard Vanguard Medical Associates showing the complexity of clinical work in medicine and the national data showing the frequency of death in surgery. In addition, Katy Thompson helped me with the research and fact-checking behind my New Yorker article "The Checklist," which this book grew out of.
Lastly, we come to those without whom my life in writing and research and surgery would be impossible. Elizabeth Morse, my administrative director, has proved irreplaceable, lending a level head, around-the-clock support, and continually wise counsel. Michael Zinner, the chairman of my surgery department at Brigham and Women's Hospital, and Arnie Epstein, the chairman of my health policy and management department at the Harvard School of Public Health, have backed me in this project as they have for many others over the last decade and more. David Remnick, the editor of the New Yorker, has been nothing but kind and loyal, keeping me on staff through this entire period. I could not be more fortunate to have such extraordinary people behind me.
Most important, however, are two final groups. There are my patients, both those who have let me tell their stories here and those who have simply trusted me to try to help with their care. I have learned more from them than from anyone else. And then there is my family. My wife, Kathleen, and children, Hunter, Hattie, and Walker, tend to suffer the brunt of my mutating c
ommitments and enthusiasms. But they have always found ways to make room for my work, to share in it, and to remind me that it is not everything. My thanks to them are boundless.
ABOUT THE AUTHOR
Atul Gawande is the author of Better and Complications. A MacArthur Fellow, a general and endocrine surgeon at the Brigham and Women's Hospital in Boston, a staff writer for The New Yorker, and an associate professor at Harvard Medical School and the Harvard School of Public Health, he also leads the World Health Organization's Safe Surgery Saves Lives program. He lives with his wife and three children in Newton, Massachusetts.