The Checklist Manifesto

How to get things right

By Atul Gawande

One thing we tend to hate thinking about is the fact that mistakes happen. They happen to everyone. Every day we make multiple mistakes, frequently with very little consequences. But what about when your surgeon meticulously and expertly amputates a limb? Only they amputate the good leg. Mistakes still happen, even when lives are in our hands. It’s inevitable, because we are human. 

The more complex and advanced our medical care becomes, the more opportunities exist for mistakes to occur. The more staff a procedure requires; the more steps in the procedure; the greater the unfamiliarity with the steps- the greater the chance for mistakes. No one means for them to happen. Most of us are utterly devastated when they do. But they will. 

There are other industries that have equally risky consequences to mistakes, which Dr. Gawande introduces to us. The aviation industry has taken an incredibly complex, high consequence skillset and minimized the number of mistakes by utilizing checklists for the pilots. A checklist addresses two of the greatest challenges to experts: 1. Fallibility of memory and attention, and 2. Complacency. 

Memory and attention is easily compromised in the veterinary field. We all have those days when every patient has very urgent needs competing with each other, and their owners and your technicians are all vying for your attention and help! To make things worse, stress and fatigue directly impact memory and attention. One can only imagine how this might impact the surgical team called in at 3am after a fully packed schedule the day before and day of! And complacency? When was the last time you verified the steristrip in your surgical pack? It’s so easy to bypass, because there are so many other things going on, and when was it ever not sterile?! 

Checklists:

1. Protect us against failure to focus/remember and complacency. They provide a form of verification, and hold us to the highest performance standard. 

2. Give ALL members of the patient care team a voice in ensuring highest standards. Hospitals are notorious for having a hierarchical culture, and when you are on the bottom of the social ladder, the courage it takes to point out that the emperor is naked, so to speak, may be insurmountable. Checklists give ALL staff the ability to be patient advocates, without fear of appearing to overstep their position.  

3. Set a higher baseline performance. Implementing checklists in a human hospital dropped infection rates from central line placement from 11% to ZERO %! A study in the veterinary field found that implementing a surgical checklist dropped the overall complication rate from 17% to 7%! (Bergstrom, et al) 

4. Establish open communication. Some of the greatest errors and disasters in any walk of life occur because of a failure to communicate. In the specialized environment, or even the busy, chaotic, general practice or emergency room you have multiple individuals managing different aspects of care for the patient. Those individuals can easily have different parts of the puzzle to the patient’s overall care, and other members of the team may need to make decisions in which that puzzle piece can play a critical role. 

5. They provide an outline for basic management of complex problems. Checklists are not meant to replace thinking, expert experience or problem solving. However, they help ensure that some of the basic, easily missed or forgettable components of a complex problem aren’t neglected. 

Dr. Gawande is a human surgeon, and in the book he outlines the development, process, hurdles and trials and errors of implementing a checklist within the medical field to minimize the risks of surgery. While the principles can be applied to any area in veterinary medicine where you find repeatable errors or mistakes, the area that has garnered the most attention and implementation is surgery. Dr. Gawande describes “four big killers” as the major contributors to surgical morbidity: infection, bleeding, unsafe anesthesia and the unexpected. Therefore, most surgical checklists in use strongly focus on these components: Has antibiotics been given within 60 minutes of initial incision? Is blood loss expected? Are there blood products available, if necessary? Has your patient been blood typed? Is the surgeon intending any procedures that may impact anesthesia, which the anesthetists can prepare for and respond appropriately? (read: dissecting the liver off of the heart? They don’t like that surprise, FYI!). Is there potential for unexpected surprises that other members of the team may not know to anticipate? Problems can be solved before they become critical. The antibiotic that was missed can be given before the incision is started. The anesthesia equipment that has a high probability of contaminating the operating personnel can be moved.  

A less intuitive component that is frequently included (especially in the human medical field) is for everyone to introduce themselves by name and role. It is rare in the general veterinary practice that everyone in the OR doesn’t know each other. But move to the specialty hospitals and university settings, and it is very possible that the faculty surgeon doesn’t know the name of the new veterinary technician in training, and vice versa. Not only does it minimize confusion or lack of understanding in roles and responsibilities, but research gives strong evidence that this simple step has a big impact on the psychology of the team working on the patient. Individuals feel more empowered, involved and responsible when this basic information is clearly verbalized. 

Challenges in designing a checklist include making it complete, yet simple. If the checklist process is too complicated, it can create new errors, become too burdensome to implement, or be outright resisted by overworked staff. Keep it as basic as you think you can make it! Another challenge is simply remembering. Routine is helpful, but trying to add a new step to a routine can be overwhelmingly hard. Methods of prompting completion of the checklist include withholding surgical blades until the checklist is complete, covering the blade handle with a device to prompt recollection of the added step, or a prominent reminder or note placed over access to a critical piece of equipment.
Introduction of a checklist may be highly resisted if it is perceived in the wrong light. A checklist is NOT meant to point fingers, shift blame or responsibility or imply that anyone is not doing their job. The leaders introducing the checklist should be implicit that the goal is strictly improving quality patient care and minimizing risk!
Finally, no checklist will be perfect in its first draft! You will find that some steps are unclear, or unnecessary as you begin to use it. Plan for revisions! Don’t give up if your first draft is not perfect- use the opportunity to revise it! Every hospital, every team, every situation has its own unique challenges, and thus the checklist should be adapted to your specific situation!

The Checklist Manifesto is a fascinating example of practicing what Dr. Gawande discusses in another very useful book on performance, Better. The veterinary profession could gain so much from implementing the lessons Dr. Gawande learned in his quest! The World Health Organization has published a basic outline for a surgical checklist that may be a good beginning point if you wish to develop one of your own. There are a few studies out there that have evaluated implementation of checklists within our field, and most of the publications have a copy of their checklist in the appendix. These make great resources for starting your own. And honestly, I am very happy to serve as a resource for you if you find you are running into problems. I personally bring a checklist to any hospital I work at that doesn’t already have one in play. I am usually working with individuals who are strangers to me, in an environment that has an unfamiliar work flow, and new or unusual practices. There are far too many opportunities for me to make a mistake, or for my adopted team to be unfamiliar with my expectations, understanding of protocol, or even be nervous or fearful of pointing out something they think I should know! We share a patient, and a common goal for that patient, and that patient deserves our very best efforts and skills. As simple as it sounds, a checklist is the least we can do for them! 

Shoot me a message or e-mail if I can help you in your quest to offer the best for your patients!

References:
Bergstrom, et al. Vet Surg 45 (2016) 571-576 Reduction of Surgical Complications in Dogs and Cats. 

Menoud, et al. Frontiers in Veterinary Science (2018) 5:60 Development and Implementation of a Perianesthetic Safety Checklist in a Veterinary University Small Animal Teaching Hospital

The World Health Organization: https://www.who.int/patientsafety/topics/safe-surgery/checklist/en/