October 21, 2014
   
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The Checklist Manifesto: How to Get Things Right

 
Editor's Note:
Medicine is a field of growing complexity and high risk. Atul Gawande, surgeon, Harvard Medical School professor and author of Better and Complications was asked by the World Health Organization to come up with a way to reduce death and complications from medical errors around the globe.

What he came up with was a checklist. This a simple tool helps keep knowledge in the driver's seat when complexity threatens to overwhelm an individual's ability to remember to do everything they know is right, whether they are performing surgery, piloting a plane in difficult conditions, building a skyscraper or trying to figure out how to make a restaurant run smoothly.


Introduction
I was chatting with a medical school friend of mine who is now a general surgeon in San Francisco. We were trading war stories, as surgeons are apt to do. One of John’s was about a guy who came in on Halloween night with a stab wound. He had been at a costume party. He got into an altercation. And now here he was.

He was stable, breathing normally, not in pain, just drunk and babbling to the trauma team. They cut off his clothes with shears and looked him over from head to toe, front and back. He was of moderate size, about two hundred pounds, most of the excess around his middle. That was where they found the stab wound, a neat two− inch red slit in his belly, pouting open like a fish mouth. A thin mustard yellow strip of omental fat tongued out of it— fat from inside his abdomen, not the pale yellow, superficial fat that lies beneath the skin. They’d need to take him to the operating room, check to make sure the bowel wasn’t injured, and sew up the little gap.

If it were a bad injury, they’d need to crash into the operating room— stretcher flying, nurses racing to get the surgical equipment set up, the anesthesiologists skipping their detailed review of the medical records. But this was not a bad injury. They had time, they determined. He lay waiting on his stretcher in the stucco− walled trauma bay while the OR was readied.

Then a nurse noticed he’d stopped babbling. His heart rate had skyrocketed. His eyes were rolling back in his head. He didn’t respond when she shook him. She called for help and the members of the trauma team swarmed back into the room. His blood pressure was barely detectible. They stuck a tube down his airway and pushed air into his lungs, poured fluid and emergency−release blood into him. Still they couldn’t get his pressure up.

The blood was everywhere. The assailant’s knife had gone more than a foot through the man’s skin, through the fat, through the muscle, past the intestine, along the left of his spinal column, and right into the aorta, the main artery from the heart.

So now they were crashing into the operating room— stretcher flying, nurses racing to get the surgical equipment set up, the anesthesiologists skipping their review of the records, a resident splashing a whole bottle of Betadine antiseptic onto his belly, John grabbing a fat No. 10 blade and slicing down through the skin of the man’s abdomen in one clean, determined swipe from rib cage to pubis.

“Cautery.”

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