The Checklist

By Atul Gawande

Medicine today has entered its B-17 phase. Many parts of what hospitals do—most notably, intensive care—are too complex for staff to carry them out reliably from memory alone. Intensive care has become “too much medicine for one person to fly.” But it is not clear that something as simple as a checklist can be of help in medical care. Sick people are much more variable than airplanes.

In 2001, a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost decided to try. He didn’t make a checklist to cover everything; he wrote one for just one problem: line infections. On a sheet of paper, he wrote down the steps to take in order to avoid infections when putting a line in. Doctors are supposed to (1) wash their hands with soap; (2) clean the patient’s skin with antiseptic, (3) put sterile covers over the entire patient, (4) wear a sterile mask, hat, coat, and gloves, and (5) put sterile gauze over the site once the line is in. These steps have been known and taught for years. So, it seemed silly to make a checklist just for them. Still, Pronovost asked the nurses to observe the doctors for a month and record how often they completed each step. In more than a third of patients, they forgot at least one step.

The next month, he persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary.

This was revolutionary. Nurses have always had their ways of reminding a doctor to do the right thing, from the gentle reminder (“Um, did you forget to put on your mask, doctor?”) to more direct methods. But many nurses aren’t sure whether this is their place, or whether a given step is worth a confrontation. The new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have support from the administration to intervene.

Pronovost and his colleagues monitored what happened during the following year. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven per cent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that the checklist had prevented forty-three infections and eight deaths, and saved more than two million dollars.

Checklists provided two main benefits. First, they helped with memory recall of ordinary tasks that could be easily overlooked. A second effect was to make clear the minimum, expected steps in a complex process. Pronovost was surprised to discover how often even experienced personnel failed to understand the importance of certain steps. Checklists established a higher standard of baseline performance.

This may all seem common sense. Yet Pronovost is described by colleagues as “brilliant,” “inspiring,” a “genius.” He has an M.D. and a Ph.D. in public health, and is trained in emergency medicine, anesthesiology, and critical-care medicine. But, really, does it take all that to understand what house movers, wedding planners, and tax accountants realized ages ago?

Based on “The Checklist”, The New Yorker, December 10, 2007.  https://www.newyorker.com/magazine/2007/12/10/the-checklist