The Checklist Manifesto (18 page)

Nonetheless, we went ahead with our eight institutions. The goal, after all, was not to compare one hospital with another but to determine where, if anywhere, the checklist could improve care. We hired local research coordinators for the hospitals and trained them to collect accurate information on deaths and complications. We were conservative about what counted. The complications had to be significant—a pneumonia, a heart attack, bleeding requiring a return to the operating room or more than four units of blood, a documented wound infection, or the like. And the occurrence had to actually be witnessed in the hospital, not reported from elsewhere.

We collected data on the surgical care in up to four operating rooms at each facility for about three months before the checklist went into effect. It was a kind of biopsy of the care received by patients across the range of hospitals in the world. And the results were sobering.

Of the close to four thousand adult surgical patients we followed, more than four hundred developed major complications resulting from surgery. Fifty-six of them died. About half the complications involved infections. Another quarter involved technical failures that required a return trip to the operating room to stop bleeding or repair a problem. The overall complication rates ranged from 6 percent to 21 percent. It’s important to note that the operating rooms we were studying tended to handle the hospital’s
more complex procedures. More straightforward operations have lower injury rates. Nonetheless, the pattern confirmed what we’d understood: surgery is risky and dangerous wherever it is done.

We also found, as we suspected we would, signs of substantial opportunity for improvement everywhere. None of the hospitals, for example, had a routine approach to ensure that teams had identified, and prepared for, cases with high blood-loss risk, or conducted any kind of preoperative team briefing about patients. We tracked performance of six specific safety steps: the timely delivery of antibiotics, the use of a working pulse oximeter, the completion of a formal risk assessment for placing an airway tube, the verbal confirmation of the patient’s identity and procedure, the appropriate placement of intravenous lines for patients who develop severe bleeding, and finally a complete accounting of sponges at the end of the procedure. These are basics, the surgical equivalent of unlocking the elevator controls before airplane takeoff. Nevertheless, we found gaps everywhere. The very best missed at least one of these minimum steps 6 percent of the time—once in every sixteen patients. And on average, the hospitals missed one of them in a startling two-thirds of patients, whether in rich countries or poor. That is how flawed and inconsistent surgical care routinely is around the world.

Then, starting in spring 2008, the pilot hospitals began implementing our two-minute, nineteen-step surgery checklist. We knew better than to think that just dumping a pile of copies in their operating rooms was going to change anything. The hospital leaders committed to introducing the concept systematically. They made presentations not only to their surgeons but also to their anesthetists, nurses, and other surgical personnel.
We supplied the hospitals with their failure data so the staff could see what they were trying to address. We gave them some PowerPoint slides and a couple of YouTube videos, one demonstrating “How to Use the Safe Surgery Checklist” and one—a bit more entertaining—entitled “How Not to Use the Safe Surgery Checklist,” showing how easy it is to screw everything up.

We also asked the hospital leaders to introduce the checklist in just one operating room at first, ideally in procedures the chief surgeon was doing himself, with senior anesthesia and nursing staff taking part. There would surely be bugs to work out. Each hospital would have to adjust the order and wording of the checklist to suit its particular practices and terminology. Several were using translations. A few had already indicated they wanted to add extra checks. For some hospitals, the checklist would also compel systemic changes—for example, stocking more antibiotic supplies in the operating rooms. We needed the first groups using the checklist to have the seniority and patience to make the necessary modifications and not dismiss the whole enterprise.

Using the checklist involved a major cultural change, as well—a shift in authority, responsibility, and expectations about care—and the hospitals needed to recognize that. We gambled that their staff would be far more likely to adopt the checklist if they saw their leadership accepting it from the outset.

My team and I hit the road, fanning out to visit the pilot sites as the checklist effort got under way. I had never seen surgery performed in so many different kinds of settings. The contrasts were even starker than I had anticipated and the range of problems was infinitely wider.

In Tanzania, the hospital was two hundred miles of sometimes one-lane dirt roads from the capital, Dar es Salaam, and flooding during the rainy season cut off supplies—such as medications and anesthetic gases—often for weeks at a time. There were thousands of surgery patients, but just five surgeons and four anesthesia staff. None of the anesthetists had a medical degree. The patients’ families supplied most of the blood for the blood bank, and when that wasn’t enough, staff members rolled up their sleeves. They conserved anesthetic supplies by administering mainly spinal anesthesia—injections of numbing medication directly into the spinal canal. They could do operations under spinal that I never conceived of. They saved and resterilized their surgical gloves, using them over and over until holes appeared. They even made their own surgical gauze, the nurses and anesthesia staff sitting around an old wood table at teatime each afternoon cutting bolts of white cotton cloth to size for the next day’s cases.

In Delhi, the charity hospital was not as badly off as the Tanzanian site or hospitals I’d been to in rural India. There were more supplies. The staff members were better trained. But the volume of patients they were asked to care for in this city of thirteen million was beyond comprehension. The hospital had seven fully trained anesthetists, for instance, but they had to perform twenty thousand operations a year. To provide a sense of how ludicrous this is, our New Zealand pilot hospital employed ninety-two anesthetists to manage a similar magnitude of surgery. Yet, for all the equipment shortages, power outages, waiting lists, fourteen-hour days, I heard less unhappiness and complaining from the surgical staff in Delhi than in many American hospitals I’ve been to.

The differences were not just between rich and poor settings,
either. Each site was distinctive. St. Mary’s Hospital, for example, our London site, was a compound of red brick and white stone buildings more than century and a half old, sprawling over a city block in Paddington. Alexander Fleming discovered penicillin here in 1928. More recently, under its chairman of surgery, Lord Darzi of Denham, the hospital has become an international pioneer in the development of minimally invasive surgery and surgical simulation. St. Mary’s is modern, well equipped, and a draw for London’s powerful and well-to-do—Prince William and Prince Harry were born here, for example, and Conservative Party leader David Cameron’s severely disabled son was cared for here, as well. But it is hardly posh. It remains a government hospital in the National Health Service, serving any Briton without charge or distinction.

Walking through St. Mary’s sixteen operating rooms, I found they looked much the same as the ones where I work in Boston—high-tech, up-to-date. But surgical procedures seemed different at every stage. The patients were put to sleep outside the operating theater, instead of inside, and then wheeled in, which meant that the first part of the checklist would have to be changed. The anesthetists and circulating nurses didn’t wear masks, which seemed like sacrilege to me, although I had to admit their necessity is unproven for staff who do not work near the patient’s incision. Almost every term the surgical teams used was unfamiliar. We all supposedly spoke English, but I was often unsure what they were talking about.

In Jordan, the working environment was also at once recognizable and alien, but in a different way. The operating rooms in Amman had zero frills—this was a still-developing country and the equipment was older and heavily used—but they had most of
the things I am used to as a surgeon, and the level of care seemed very good. One of the surgeons I met was Iraqi. He’d trained in Baghdad and practiced there until the chaos following the American invasion in 2003 forced him to flee with his family, abandoning their home, their savings, and his work. Before Saddam Hussein, in the last years of his rule, gutted the Iraqi medical system, Baghdad had provided some of the best medical care in the Middle East. But, the surgeon said, Jordan now seemed positioned to take that role and he felt fortunate to be there. I learned that more than 200,000 foreign patients travel to Jordan for their health care each year, generating as much as one billion dollars in revenues for the country.

What I couldn’t work out, though, was how the country’s strict gender divide was negotiated in its operating rooms. I remember sitting outside a restaurant the day I arrived, studying the people passing by. Men and women were virtually always separated. Most women covered their hair. I got to know one of the surgery residents, a young man in his late twenties who was my guide for the visit. We even went out to see a movie together. When I learned he had a girlfriend of two years, a graduate student, I asked him how long it was before he got to see her hair.

“I never have,” he said.

“C’mon. Never?”

“Never.” He’d seen a few strands. He knew she had dark brown hair. But even in the more modern dating relationship of a partly Westernized, highly educated couple, that was it.

In the operating rooms, all the surgeons were men. Most of the nurses were women. The anesthetists split half and half. Given the hierarchies, I wondered whether the kind of team-work envisioned by the checklist was even possible. The women
wore their head scarves in the operating rooms. Most avoided eye contact with men. I slowly learned, however, that not all was what it seemed. The staff didn’t hesitate to discard the formalities when necessary. I saw a gallbladder operation in which the surgeon inadvertently contaminated his glove while adjusting the operating lights. He hadn’t noticed. But the nurse had.

“You have to change your glove,” the nurse told him in Arabic. (Someone translated for me.)

“It’s fine,” the surgeon said.

“No, it’s not,” the nurse said. “Don’t be stupid.” Then she made him change his glove.

For all the differences among the eight hospitals, I was nonetheless surprised by how readily one could feel at home in an operating room, wherever it might be. Once a case was under way, it was still surgery. You still had a human being on the table, with his hopes and his fears and his body opened up to you, trusting you to do right by him. And you still had a group of people striving to work together with enough skill and commitment to warrant that trust.

The introduction of the checklist was rocky at times. We had our share of logistical hiccups. In Manila, for instance, it turned out there was only one nurse for every four operations, because qualified operating nurses kept getting snapped up by American and Canadian hospitals. The medical students who filled in were often too timid to start the checklist, so the anesthesia staff had to be persuaded to take on the task. In Britain, the local staff had difficulties figuring out the changes needed to accommodate their particular anesthesia practices.

There was a learning curve, as well. However straightforward the checklist might appear, if you are used to getting along without
one, incorporating it into the routine is not always a smooth process. Sometimes teams forgot to carry out part of the checklist—especially the sign-out, before taking the patient from the room. Other times they found adhering to it just too hard—though not because doing so was complicated. Instead, the difficulty seemed to be social. It felt strange to people just to get their mouths around the words—for a nurse to say, for example, that if the antibiotics hadn’t been given, then everyone needed to stop and give them before proceeding. Each person has his or her style in the operating room, especially surgeons. Some are silent, some are moody, some are chatty. Very few knew immediately how to adapt their style to huddling with everyone—even the nursing student—for a systematic run-through of the plans and possible issues.

The introduction of names and roles at the start of an operating day proved a point of particularly divided view. From Delhi to Seattle, the nurses seemed especially grateful for the step, but the surgeons were sometimes annoyed by it. Nonetheless, most complied.

Most but not all. We were thrown out of operating rooms all over the world. “This checklist is a waste of time,” we were told. In a couple places, the hospital leaders wanted to call the curmudgeons on the carpet and force them to use it. We discouraged this. Forcing the obstinate few to adopt the checklist might cause a backlash that would sour others on participating. We asked the leaders to present the checklist as simply a tool for people to try in hopes of improving their results. After all, it remained possible that the detractors were right, that the checklist would prove just another well-meaning effort with no significant effect whatsoever.

Pockets of resistance notwithstanding, the safe surgery checklist effort was well under way within a month in each location, with teams regularly using the checklist in every operating room we were studying. We continued monitoring the patient data. I returned home to wait out the results.

I was nervous about the project. We had planned to examine the results for only a short time period, about three months in each pilot site after introduction of the checklist. That way any changes we observed would likely be the consequence of the checklist and not of long-term, ongoing trends in health or medical care. But I worried whether anything could really change in so short a time. The teams were clearly still getting the hang of things. Perhaps we hadn’t given them enough time to learn. I also worried about how meager the intervention was when you got right down to it. We’d provided no new equipment, staff, or clinical resources to hospitals. The poor places were still poor, and we had to wonder whether improvement in their results was really possible without changing that. All we’d done was give them a one-page, nineteen-item list and shown them how to use it. We’d worked hard to make it short and simple, but perhaps we’d made it too short and too simple—not detailed enough. Maybe we shouldn’t have listened to the aviation gurus.