Gawande on Checklists: Why Don't Hospitals Use Them?

Cheryl Clark, February 3, 2011

Brigham and Women's Hospital surgeon Atul Gawande, MD, is on the road talking up one of his favorite topics: Checklists. You could say he wrote the book on them, "The Checklist Manifesto."

On Wednesday Gawande talked at a Scripps Quality Summit in San Diego about how the 19-point system he and others developed is proving every day that its use can reduce surgical deaths, complications, surgical site infections, and unplanned reoperations.  

Death rate dropped from 1.5% to .8%; complication rate from 11% to 7%; surgical site infections, from 6.2% to 3.4% and unplanned reoperations, 2.4% to 1.8% as measured within the first 30 days in eight hospital sites globally, after his surgical checklists were adopted, he said.

He also talked about how hard it is to get providers to adopt those checklists, that they are controversial, and listed some of the reasons many providers are resistant, even with so much evidence that they improve care. Gawande told his audience that providers largely think they alone are responsible for the treatments they administer to one patient, but in fact, it takes 19.5 full-time equivalent positions to make that process happen.

Gawande recounted one bone-chilling example of how the failure to perform one thing – the administration of a simple vaccine that should have been part of routine medical procedure – caused the system to disastrously fail for one young man.

It was the story of Duane Smith, a 34-year old grocery store worker from Texas, who got in a terrible vehicle collision while driving in Boston.

"He'd had a broken leg, broken pelvis, broken arm, bilateral lung collapse and internal bleeding from an unknown source. The team that took care of him worked like clockwork. The EMTs got on the scene immediately. They extracted him, gave volume resuscitation, and kept him alive. They transported him rapidly to the nearest level one trauma center.

"There in the emergency room, they enumerated and found every injury, identified bilateral lung collapse and needed chest tubes, confirmed the bleeding was not coming from his chest and moved him to an operating room so that his ruptured spleen (could be) removed."


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