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In his latest bestseller, Atul Gawande shows what the simple idea of the checklist reveals about the complexity of our lives and how we can deal with it. The modern world has given us stupendous know-how. Yet avoidable failures continue to plague us in health care, government, the law, the financial industry—in almost every realm of organized activity. And the reason is simple: the volume and complexity of knowledge today has exceeded our ability as individuals to properly deliver it to people—consistently, correctly, safely. We train longer, specialize more, use ever-advancing technologies, and still we fail. Atul Gawande makes a compelling argument that we can do better, using the simplest of methods: the checklist. In riveting stories, he reveals what checklists can do, what they can’t, and how they could bring about striking improvements in a variety of fields, from medicine and disaster recovery to professions and businesses of all kinds. And the insights are making a difference. Already, a simple surgical checklist from the World Health Organization designed by following the ideas described here has been adopted in more than twenty countries as a standard for care and has been heralded as “the biggest clinical invention in thirty years” (The Independent).
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In complex situations – such as those which arise in almost every profession and industry today – the solutions to problems are technical and demanding. There are often a variety of different ways to solve a problem. It’s all too easy to get so caught up dealing with all these complexities that the most obvious and common sense immediate solutions are not tried first. To overcome this problem, take a leaf from the commercial aviation industry and develop checklists people can use to make sure every base is covered quickly and concisely. Checklists are a forgotten or ignored business tool. It’s time for them to come in from the cold.
Modern medical care is a good example of how professional fields of expertise have developed in recent years with the coming of the information revolution. Today’s medical practitioners are extremely educated and superbly experienced in their areas of expertise, but that increase in specialization is bringing about some unintended consequences. Everyone is getting so busy in their respective areas of expertise some basic and preventable patients deaths are occurring.
Medical care in the twenty-first century is highly impressive. Saves are made daily of patients who just a few years ago would have faced certain death. For all those achievements, however, a surprising number of patients still die due to some very basic human errors:
■ Medical machinery which has not been properly serviced and therefore which is not working when it is needed in an emergency setting.
■ Teams that can’t get moving fast enough in order to perform a needed procedure.
■ Someone somewhere along the line forgets to wash their hands and an infection takes hold with fatal consequences.
The World Health Organization has estimated there are now more than thirteen thousand different diseases, syndromes and types of injury. For nearly all of them, science has provided things that can be done to help – either by curing the disease or by reducing the harm and misery involved. The challenge is for each condition, the treatment steps are different and they are almost always complex. The average clinician has about six thousand drugs and around four thousand medical and surgical procedures to choose from. This is a lot for someone to get right, even someone who has been trained for many years.
On any given day in the United States, around ninety thousand people will be admitted to intensive care. That means over a year, some five million Americans will receive intensive care and almost everyone will get to see the inside of an intensive care unit over the course of their lifetime. According to one study, the average patient in intensive care will require 178 individual actions per day – administering a drug at the right time, turning the patients regularly to avoid bed sores, having someone bathe them and change their sheets without disturbing tubes or lines which may been inserted, etc. Every one of these actions involves risks and doctors and nurses do a remarkable job in minimizing mistakes but even an error of just one percent will mean two mistakes per day per patient are being made.
“This is the reality of intensive care: at any point, we are as apt to harm as we are to heal. Line infections are so common they are considered a routine complication. ICUs put five million lines into patients each year, and national statistics show that after ten days 4 percent of those lines become infected. Line infections occur in eighty thousand people a year in the United States and are fatal between 5 and 28 percent of the time, depending on how sick one is at the start. Those who survive line infections spend on average a week longer in intensive care. And this is just one of many risks. All in all, about half of ICU patients end up experiencing a serious complication, and once that occurs the chances of survival drop sharply.” — Atul Gawande
The medical profession’s answer to all this increasing complexity thus far has been:
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