The Checklist Manifesto (2 page)

Lack of oxygen was also a possibility. I said I’d put the oxygen at 100 percent and check the airway. I’d also draw blood and send it for stat laboratory tests to rule out unusual abnormalities.

John said they thought of that, too. The airway was fine. And as for the lab tests, they would take at least twenty minutes to get results, by which point it would be too late.

Could it be a collapsed lung—a pneumothorax? There were no signs of it. They listened with a stethoscope and heard good air movement on both sides of the chest.

The cause therefore had to be a pulmonary embolism, I said—a blood clot must have traveled to the patient’s heart and plugged off his circulation. It’s rare, but patients with cancer
undergoing major surgery are at risk, and if it happens there’s not much that can be done. One could give a bolus of epinephrine—adrenalin—to try to jump-start the heart, but it wouldn’t likely do much good.

John said that his team had come to the same conclusion. After fifteen minutes of pumping up and down on the patient’s chest, the line on the screen still flat as death, the situation seemed hopeless. Among those who arrived to help, however, was a senior anesthesiologist who had been in the room when the patient was being put to sleep. When he left, nothing seemed remotely off-kilter. He kept thinking to himself, someone must have done something wrong.

He asked the anesthesiologist in the room if he had done anything different in the fifteen minutes before the cardiac arrest.

No. Wait. Yes. The patient had had a low potassium level on routine labs that were sent during the first part of the case, when all otherwise seemed fine, and the anesthesiologist had given him a dose of potassium to correct it.

I was chagrined at having missed this possibility. An abnormal level of potassium is a classic cause of asystole. It’s mentioned in every textbook. I couldn’t believe I overlooked it. Severely low potassium levels can stop the heart, in which case a corrective dose of potassium is the remedy. And too much potassium can stop the heart, as well—that’s how states execute prisoners.

The senior anesthesiologist asked to see the potassium bag that had been hanging. Someone fished it out of the trash and that was when they figured it out. The anesthesiologist had used the wrong concentration of potassium, a concentration one hundred times higher than he’d intended. He had, in other words, given the patient a lethal overdose of potassium.

After so much time, it wasn’t clear whether the patient could be revived. It might well have been too late. But from that point on, they did everything they were supposed to do. They gave injections of insulin and glucose to lower the toxic potassium level. Knowing that the medications would take a good fifteen minutes to kick in—way too long—they also gave intravenous calcium and inhaled doses of a drug called albuterol, which act more quickly. The potassium levels dropped rapidly. And the patient’s heartbeat did indeed come back.

The surgical team was so shaken they weren’t sure they could finish the operation. They’d not only nearly killed the man but also failed to recognize how. They did finish the procedure, though. John went out and told the family what had happened. He and the patient were lucky. The man recovered—almost as if the whole episode had never occurred.

The stories surgeons tell one another are often about the shock of the unexpected—the bayonet in San Francisco, the cardiac arrest when all seemed fine—and sometimes about regret over missed possibilities. We talk about our great saves but also about our great failures, and we all have them. They are part of what we do. We like to think of ourselves as in control. But John’s stories got me thinking about what is really in our control and what is not.

In the 1970s, the philosophers Samuel Gorovitz and Alasdair MacIntyre published a short essay on the nature of human fallibility that I read during my surgical training and haven’t stopped pondering since. The question they sought to answer was why we fail at what we set out to do in the world. One reason, they observed, is “necessary fallibility”—some things we want to do
are simply beyond our capacity. We are not omniscient or all-powerful. Even enhanced by technology, our physical and mental powers are limited. Much of the world and universe is—and will remain—outside our understanding and control.

There are substantial realms, however, in which control is within our reach. We can build skyscrapers, predict snowstorms, save people from heart attacks and stab wounds. In such realms, Gorovitz and MacIntyre point out, we have just two reasons that we may nonetheless fail.

The first is ignorance—we may err because science has given us only a partial understanding of the world and how it works. There are skyscrapers we do not yet know how to build, snowstorms we cannot predict, heart attacks we still haven’t learned how to stop. The second type of failure the philosophers call ineptitude—because in these instances the knowledge exists, yet we fail to apply it correctly. This is the skyscraper that is built wrong and collapses, the snowstorm whose signs the meteorologist just plain missed, the stab wound from a weapon the doctors forgot to ask about.

Thinking about John’s cases as a small sample of the difficulties we face in early-twenty-first-century medicine, I was struck by how greatly the balance of ignorance and ineptitude has shifted. For nearly all of history, people’s lives have been governed primarily by ignorance. This was nowhere more clear than with the illnesses that befell us. We knew little about what caused them or what could be done to remedy them. But sometime over the last several decades—and it is only over the last several decades—science has filled in enough knowledge to make ineptitude as much our struggle as ignorance.

Consider heart attacks. Even as recently as the 1950s, we had
little idea of how to prevent or treat them. We didn’t know, for example, about the danger of high blood pressure, and had we been aware of it we wouldn’t have known what to do about it. The first safe medication to treat hypertension was not developed and conclusively demonstrated to prevent disease until the 1960s. We didn’t know about the role of cholesterol, either, or genetics or smoking or diabetes.

Furthermore, if someone had a heart attack, we had little idea of how to treat it. We’d give some morphine for the pain, perhaps some oxygen, and put the patient on strict bed rest for weeks—patients weren’t even permitted to get up and go to the bathroom for fear of stressing their damaged hearts. Then everyone would pray and cross their fingers and hope the patient would make it out of the hospital to spend the rest of his or her life at home as a cardiac cripple.

Today, by contrast, we have at least a dozen effective ways to reduce your likelihood of having a heart attack—for instance, controlling your blood pressure, prescribing a statin to lower cholesterol and inflammation, limiting blood sugar levels, encouraging exercise regularly, helping with smoking cessation, and, if there are early signs of heart disease, getting you to a cardiologist for still further recommendations. If you should have a heart attack, we have a whole panel of effective therapies that can not only save your life but also limit the damage to your heart: we have clot-busting drugs that can reopen your blocked coronary arteries; we have cardiac catheters that can balloon them open; we have open heart surgery techniques that let us bypass the obstructed vessels; and we’ve learned that in some instances all we really have to do is send you to bed with some oxygen, an aspirin, a statin, and blood pressure medications—in a couple
days you’ll generally be ready to go home and gradually back to your usual life.

But now the problem we face is ineptitude, or maybe it’s “eptitude”—making sure we apply the knowledge we have consistently and correctly. Just making the right treatment choice among the many options for a heart attack patient can be difficult, even for expert clinicians. Furthermore, what ever the chosen treatment, each involves abundant complexities and pitfalls. Careful studies have shown, for example, that heart attack patients undergoing cardiac balloon therapy should have it done within ninety minutes of arrival at a hospital. After that, survival falls off sharply. In practical terms this means that, within ninety minutes, medical teams must complete all their testing for every patient who turns up in an emergency room with chest pain, make a correct diagnosis and plan, discuss the decision with the patient, obtain his or her agreement to proceed, confirm there are no allergies or medical problems that have to be accounted for, ready a cath lab and team, transport the patient, and get started.

What is the likelihood that all this will actually occur within ninety minutes in an average hospital? In 2006, it was less than 50 percent.

This is not an unusual example. These kinds of failures are routine in medicine. Studies have found that at least 30 percent of patients with stroke receive incomplete or inappropriate care from their doctors, as do 45 percent of patients with asthma and 60 percent of patients with pneumonia. Getting the steps right is proving brutally hard, even if you know them.

I have been trying for some time to understand the source of our greatest difficulties and stresses in medicine. It is not money
or government or the threat of malpractice lawsuits or insurance company hassles—although they all play their role. It is the complexity that science has dropped upon us and the enormous strains we are encountering in making good on its promise. The problem is not uniquely American; I have seen it everywhere—in Europe, in Asia, in rich countries and poor. Moreover, I have found to my surprise that the challenge is not limited to medicine.

Know-how and sophistication have increased remarkably across almost all our realms of endeavor, and as a result so has our struggle to deliver on them. You see it in the frequent mistakes authorities make when hurricanes or tornadoes or other disasters hit. You see it in the 36 percent increase between 2004 and 2007 in lawsuits against attorneys for legal mistakes—the most common being simple administrative errors, like missed calendar dates and clerical screw ups, as well as errors in applying the law. You see it in flawed software design, in foreign intelligence failures, in our tottering banks—in fact, in almost any endeavor requiring mastery of complexity and of large amounts of knowledge.

Such failures carry an emotional valence that seems to cloud how we think about them. Failures of ignorance we can forgive. If the knowledge of the best thing to do in a given situation does not exist, we are happy to have people simply make their best effort. But if the knowledge exists and is not applied correctly, it is difficult not to be infuriated. What do you mean half of heart attack patients don’t get their treatment on time? What do you mean that two-thirds of death penalty cases are overturned because of errors? It is not for nothing that the philosophers gave these failures so unmerciful a name—
ineptitude
. Those on
the receiving end use other words, like
negligence
or even
heartlessness
.

For those who do the work, however—for those who care for the patients, practice the law, respond when need calls—the judgment feels like it ignores how extremely difficult the job is. Every day there is more and more to manage and get right and learn. And defeat under conditions of complexity occurs far more often despite great effort rather than from a lack of it. That’s why the traditional solution in most professions has not been to punish failure but instead to encourage more experience and training.

There can be no disputing the importance of experience. It is not enough for a surgeon to have the textbook knowledge of how to treat trauma victims—to understand the science of penetrating wounds, the damage they cause, the different approaches to diagnosis and treatment, the importance of acting quickly. One must also grasp the clinical reality, with its nuances of timing and sequence. One needs practice to achieve mastery, a body of experience before one achieves real success. And if what we are missing when we fail is individual skill, then what is needed is simply more training and practice.

But what is striking about John’s cases is that he is among the best-trained surgeons I know, with more than a decade on the front lines. And this is the common pattern. The capability of individuals is not proving to be our primary difficulty, whether in medicine or elsewhere. Far from it. Training in most fields is longer and more intense than ever. People spend years of sixty-, seventy-, eighty-hour weeks building their base of knowledge and experience before going out into practice on their own—whether they are doctors or professors or lawyers or engineers. They have sought to perfect themselves. It is not clear how we
could produce substantially more expertise than we already have. Yet our failures remain frequent. They persist despite remarkable individual ability.

Here, then, is our situation at the start of the twenty-first century: We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And, with it, they have indeed accomplished extraordinary things. Nonetheless, that know-how is often unmanageable. Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields—from medicine to finance, business to government. And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.

That means we need a different strategy for overcoming failure, one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our inevitable human inadequacies. And there is such a strategy—though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies.