The physicist Eugene Wigner, wondering why math works and why it is able to tell us so much about the world, once famously marveled about “the unreasonable effectiveness of mathematics in the natural sciences.” Today, researchers studying medical malpractice are marveling about the unreasonable effectiveness of following simple checklists for medical tasks.
I’ve previously blogged about Dr. Atul Gawande’s new book, “The Checklist Manifesto: How To Get Things Right.” The book concerns the outgrowth of a project that the World Health Organization (WHO) asked Dr. Gawande to work on in 2006. The WHO wanted to find the most cost-effective solution for reducing deaths and complications for surgery. Since whatever solution Dr. Gawanda and his team devised would be implemented around the world, including Third World countries, it couldn’t be an expensive or high-tech quick fix.
Eventually, inspired by checklists that he found used everywhere from construction projects to airline travel, Dr. Gawande and his team decided the single best proposal they could come up with in response to the WHO’s challenge was to implement simple medical checklists. The nineteen-step medical checklist that they drafted has, in a worldwide pilot study, reduced deaths by 47 percent and major complications by thirty-six percent. Britain’s National Institute of Health is planning to mandate the checklist’s use in British hospitals. (American hospitals, by contrast, seem reluctant to adopt the use of checklists). The idea that something as simple as a checklist could be, well, so unreasonably effective in saving patients’ lives really is something to wonder at, in this day and age of twenty-first century technology.
In his book, Gawande appears to marvel at the unreasonable effectiveness of checklists in surgery the same way that Wigner once marveled about the unreasonable effectiveness of mathematics in physics. Gawande’s book shows that checklists work but does not seem particularly interested in why they work.
Is it just as simple as, without the reminder of a checklist, a surgeon might forget to wash his hands? Does a checklist work the same way as a “cheat sheet” that a student might bring into an exam – helping him jog his memory about facts he might otherwise not recall?
Or is there some deeper magic to checklists? Gawande suggests that one possibility is that the checklists open up a more democratic/egalitarian environment in the operating room, where nurses and other personnel feel empowered to speak up and tell doctors that they did something wrong, but he devotes surprisingly little time to investigating this possibility. In my book review, drawing on some aviation history, I suggested that I thought this might be the main reason checklists proved so effective.
So I was excited this week when I read about the experience of Nebraska Medical Center, which, since 2006, has trained its personnel in airline Cockpit Resource Management (CRM) techniques, centering around a “See it, say it, fix it,” approach to patient safety. A 2007 study at Nebraska Medical found that fewer than six months into their CRM training, the percentage of medical staff who “felt free to question the decisions of those with more authority” had nearly tripled – increasing from 29 to 86 percent. Meanwhile patient safety had dramatically improved.
The egalitarian nature of airline crews, whose members are trained to be assertive and speak their minds to the captain, are one reason to feel safer on a plane than under anesthesia. But maybe some things are changing.