The March 8th New York Times publishes a remarkably insightful opinion piece by Atul Gawande. Gawande reminds us of a lesson learned long ago in a completely different professional context.
In 1935 the U.S. Army Air Corps held a flight competition for airplane manufacturers competing for the privilege of building the next generation long-range bomber. Boeing seemed, to those in the know, to be the obvious winner. It could carry five times as many bombs as the army had requested, it was fast and could travel almost twice as far as the existing equipment.
The competition was a disaster for Boeing. Moments after takeoff the plane crashed killing the pilot and two of the five crew members. After investigation it was clear that pilot error was the cause of the incident. The pilot was required to attend to four engines, retractable landing gear, wing flaps, trim tabs and propellers for each engine whose pitch had to be regulated with hydraulic controls. The pilot attending to all of these matters at the same time omitted to release a locking mechanism on the elevator and rudder controls. The contract went to Douglas Aircraft and Boeing faced financial ruin.
Fortunately, the army purchased a few of the Boeing aircraft as test planes. A group of test pilots came up with a brilliant and elegantly simple solution. They created a checklist which if followed would assure that each matter that needed to be attended would be attended to at the time and in the order necessary to assure that the pilot would not be confronted with having to recall all of the various interactions since the simplest omission could be fatal. These same pilots flew Boeing’s entry nearly 2,000,000 miles without a single accident. The army ordered 13,000 of the aircraft which became known as the B-17. This famous aircraft contributed to our victory in World War II.
The same lesson learned by the pilots who helped make the B-17 a safe aircraft have been resurrected sixty years later in an attempt to address preventable medical errors. Just as the original pilot who crashed the then experimental B-17 was overwhelmed by the many routine but essential things that needed to be done and done in a particular order, similarly physicians today face the same problem. Physicians are virtually assaulted by such a mass of information and important facts must not be overlooked, especially when to overlook a matter would be ruinous to a patient’s life.
Peter Pronovost, a critical care physician at John’s Hopkins Hospital was among the first, if not the first to give it a try. In 2001 he created a checklist designed to tackle just one recurring problem in medicine: line infections. He plotted the course one should take in order to avoid infections when putting in a venous or arterial line. 1. Wash hands with soap. 2. Clean patient’s skin with appropriate antiseptic. 3. Put sterile drapes over the entire patient. 4. Wear a sterile mask, cap, gown and gloves. 5. Put a sterile dressing over the catheter site once the line is in.
Note that these steps had nothing to do with attempting to articulate the surgical skills needed to safely place the line. Indeed, these steps have been known and taught for years. However, Pronovost had nurses in his ICU observe doctors for one month putting lines into the patients. In more than one-third of the patients the nurses observed that physicians omitted at least one step.
Pronovost was able in one year to reduce the ten-day line infection rate from 11% to 0.
What Pronovost observed is certainly a reality that we all confront. Mundane matters are easily overlooked especially in the middle of a medical emergency. Since Pronovost’s original work, other institutions have attempted similar undertakings.
Forward thinkers like Pronovost and others who followed, unfortunately are whispering in the midst of a storm. Gawande called Pronovost recently and reports a certain pessimism. According to Gawande, Pronovost told him, “At the current rate, it will never happen. The fundamental problem with the quality of American medicine is we fail to view the delivery of healthcare as a science. Once we acquire an understanding of the disease and find effective therapies for that disease, there seems little attention to assuring that the therapies are effectively delivered.”
We must not allow “The Art of Medicine” to be used as an excuse for individuality which is not a matter of informed choice but instead forgetful omission.
See related article concerning the Surgical check list.