[mhh__]

https://www.england.nhs.uk/2019/01/surgical-safety-checklist...

Getting surgeons to adopt the kind of "It's obvious but point and speak or you're fired"-style checklists a la operating an aircraft has reduced complications (from the minor to deaths) by several percent in the NHS. It's perhaps worrying given how low-hanging some of these fruit are - i.e. "Do we have the right patient?".

[bookofjoe]

Back when I was still practicing as an anesthesiologist (1977-2015) I had a pack of 3x5 cards I carried in my scrubs pocket on each of which was an exhaustively detailed list I'd made of EVERYTHING I needed at hand to perform specialized procedures such as inserting an arterial line (putting a #20g plastic catheter through the skin on the inside of the wrist into the radial artery for direct beat-to-beat monitoring of arterial blood pressure, a measurement employed for seriously ill or unstable patients). I would assemble a tray with the following items in the OR before going to ICUs or the ER because invariably one or more of the items I would need would not be present and would take time to procure.

For example:

ARTERIAL LINE

• several sterile alcohol skin wipes • 3cc syringe with 25g needle [for skin infiltration of local anesthetic at puncture site] • bottle of 2% lidocaine with epinephrine 1/1000 • 2x2 cotton gauze pads to use for pressure on failed puncture sites • 3 #20 gauge plastic catheters (22 gauge for small children) • 2 surgical towels to drape over hand and lower arm to absorb blood that accompanied successful arterial puncture • size 7.5 sterile surgical gloves for me to wear while performing procedure • specialized 1" waterproof plastic skin tape to secure and protect catheter in situ

I was constantly amazed by how my colleagues would have to stop and wait for something not present in the unit they were called to. Conversely, when I was called because of an inability to insert an A-line, as they were referred to, and wasn't in a place where I could assemble my desired materials, I'd proceed with the materials at hand, all the while thinking "this could have been done a lot better...."

[bookofjoe]

Note added after HN editing hour closed: The reason I created these Procedure Cards is that when I was really tired — for example at 1 a.m. after I'd been on call and working 18 hours since 7 a.m. the previous day, with six more hours to go till I was relieved at 7 a.m. — I invariably forgot something I needed and had to wait or make do because of this fatigue-induced lapse. With my list, I was able to do what I knew how to do without having to try and remember a zillion specific things.

[FiatLuxDave]

I wonder if you would be interested in the discussion in this recent HN thread regarding intubation (or it might all be old hat to you):

https://news.ycombinator.com/item?id=25395314

[danpalmer]

> It's perhaps worrying given how low-hanging some of these fruit are - i.e. "Do we have the right patient?"

It turns out that while it's a good idea to check things this "low-hanging", the value is far larger than catching wrong patients, so don't worry too much!

Much of the value comes from essentially disrupting routine with an opportunity to stop, and from creating a culture of speaking up. I think the NHS was the organisation to trial having the nurse run the checklist, which had the effect of empowering the "lowest level" person in the operating theatre. Studies showed that even just having everyone in the room speak once increased the chance of subsequent communication, and ultimately improved patient outcomes.

Atul Gawande was one of the key people in designing and rolling out these checklists and wrote a book about it that I'd recommend – The Checklist Manifesto.

[tomxor]

That's excellent! it never occurred to me it could have such a positive effect in a team situation. Empowering the supporting members is very insightful, they may be supporting but they are just as critical, they need to feel appreciation for the value they provide to stay sharp and motivated - I hope this can be applied to other contexts, thanks for sharing this.

[ZeroGravitas]

If I remember the anecdotes correctly, the focus on nurses wasnt as cheery as this. Basically, the nurses often knew when the surgeon was in the process of making a mistake, up to cutting the wrong leg off a patient, but kept quiet because surgeons had the power to ruin their careers if they "embarressed" them. So the innovation was really about forcing surgeons to not terrify their nurses into silence.

[tomxor]

Ouch. This reminds me of the problems nurses faced in the 80s as described in "Pragmatic Thinking and Learning". From that book it made it sounds as thought the issues were mostly historic, I guess there have been a number of different battles fought.

[Privacy846]

/delted/

[danpalmer]

Well it was about this. Empowering them against surgeons in a position of power is still empowerment.

[FabHK]

+1 on Atul Gawande's book The Checklist Manifesto. It's an interesting read if you're into aviation or healthcare or anticipate being in hospital one day.

[tomxor]

I'm probably going to sound silly now but I do this when doing any technical work I deem important or critical enough, point and say outloud what it's for or what state it should be in or in the imperative what to do to it... it does work, it somehow catches silly mistakes compared to keeping everything in your mind, and also gives you confidence because it works like a checklist.

Known as pointing and calling in transport AFAIK.

[kba]

What you're describing is very similar to Rubber duck debugging. The idea here is that forcing you to explain what you're trying to do makes it easier for you to catch your mistakes.

https://en.wikipedia.org/wiki/Rubber_duck_debugging

[mhh__]

Its absolutely not silly.

It's similar to why formal verification is so important in hardware, because it's effectively forcing you to be specific about semantics and let's the computer walk through things for you.

[rzzzt]

I do this when I am the last to leave a building. "This window is closed... these lamps are off". I read about the transport-related part of it in this article: https://www.atlasobscura.com/articles/pointing-and-calling-j...

[michaelt]

Reminds me of a scene in House, where the cynical veteran doctor about to receive surgery on his right leg uses a sharpie to write "NOT THIS LEG" on his left leg.

[FabHK]

Suboptimal. The "NOT" might be covered by something, and then what remains is "THIS LEG". I would have written "NO NO NO" on one leg, and "THIS THIS THIS" on the other.

In aviation, standard phraseology is generally carefully designed such that (mosts) subsets of a phrase are distinct from the opposite phrase. For example, when ATC warns of traffic, you reply either "traffic in sight" or "negative contact". When ATC hears only half of either, they still know what you meant.

[EvanAnderson]

I know people who have been instructed to do this by medical staff prior to surgery. I have personally helped someone mark a mole they couldn't reach on their back.

[rytis]

Can confirm - had to point to the area that was supposed to be operated while laying in pre-op (or whatever it's called) room, just before being knocked out... Was quite scary ("you should know what you're doing!"), but quite sensible on a second thought.

[roenxi]

> It's perhaps worrying given how low-hanging some of these fruit are...

You don't realise how "bad" normal operational discipline is until you've seen it done right. The risk isn't so much that people skip a step, but that phantom steps start creeping in because people aren't quite sure of the standard, that saps a surprising amount of resources away which could be used for checking mistakes. And then people get disorganised and potential holes appear.

A big part of excellence isn't doing the right steps, it is trimming out the steps that don't need to be there, to focus attention on the stuff that works.

[oblio]

People are vain. People's vanity is so strong that they are willing to kill and maim others and even do insane things such as declaring wars.

Regarding your checklist, you should read about Semmelweiss: https://en.wikipedia.org/wiki/Ignaz_Semmelweis

It's crazy to think that entire generations of doctors retired and died arguing against washing your hands!

[kennywinker]

Might have surprised me before 2020, but the amount of people throwing hissy fits over masks this year has prepared me for the ridiculous stubbornness of humans asked to change.

[poooogles]

If you want to read more on the background of this The Checklist Manifesto is a great book and has lots of applications when it comes to IT operations. Stupid checklists in markdown that you can check off as you go through have certainly improved our performance in ad hoc tasks that we don't automate.

[riffraff]

> i.e. "Do we have the right patient?".

sad anecdote: a friend of mine got surgery to remove a problematic mole on his back, and not only the surgeon got the wrong one, but even got upset with him when my friend mentioned something like "I thought it was further up my back".

[throwaway2245]

There's increasing suggestion that the claimed benefits of using checklists have not been reproducible in RCTs:

e.g. https://www.bmj.com/content/366/bmj.l4700.full

[FabHK]

One of the studied showed that teams that completed the checklist had lower mortality, but argued that the teams completing checklists might be systematically different from the teams that didn't complete the checklists, and thus the difference could not be attributed to the checklist, per se. Not wrong, but doesn't amount to refutation.

Note that in the debate you cited both, proponent and opponent, advocated the (continued) use of checklists.

Side note: I could see how you could do a blinded RCT, but not how you could do a double blind RCT here.

[throwaway2245]

I think checklists are probably just fine, but I think they are overhyped despite a lack of scientific comparison to other interventions (I would much rather have sharpie on my legs and barcodes on the surgical sponges, given the choice) - and in particular, checklists are not directly relevant to the content of this article.

[someburner]

I just got surgery in California and noticed I was asked to state my name and birthday anytime I moved rooms or saw a new person. Seems like this is now part of protocol in a lot of places.

[throwaway2245]

I've moved from a place where the protocol is "what's your name/birthday?" (while looking at a form with my name/birthday on it)

to a place where the protocol is "are you [name]?"

The difference is unnerving.

[kube-system]

That is standard procedure in the US for every trained medical professional, all the way down to the MA who measures your height and weight at a routine physical.

[ninju]

I believe a lot of that is verifying that you are the right patient

[minikites]

I got in a medium-severity bicycle accident in 2010 and while I was being whisked around the hospital for different tests and procedures I had to do that too.

[ThinkingGuy]

It's even done at Red Cross donation centers when I donate blood.

[praptak]

Procedures in hospitals are interesting. I recently visited a hospital and there was a red sign above the table where nurses dose medicines for patients: "No room numbers on trays, no bed numbers on trays". Seems like a low hanging fruit but a very non-obvious one (well at least non-obvious to me).

[MeinBlutIstBlau]

As an advocate of checklists for specific tasks, yes that stuff is good. Oftentimes there are a lot of checks that one would go "yeah no duh." But most good checklist exist with a checkbox because that was an issue before.