The Checklist Manifesto (23 page)

To my chagrin, however, I have yet to get through a week in surgery without the checklist’s leading us to catch something we would have missed. Take last week, as I write this, for instance. We had three catches in five cases.

I had a patient who hadn’t gotten the antibiotic she should have received before the incision, which is one of our most common catches. The anesthesia team had gotten distracted by the usual vicissitudes. They had trouble finding a good vein for an IV, and one of the monitors was being twitchy. Then the nurse called a time-out for the team to run the Before Incision check.

“Has the antibiotic been given within the last sixty minutes?” I asked, reading my lines off a wall poster.

“Oh, right, um, yes, it will be,” the anesthesia resident replied. We waited a quiet minute for the medication to flow in before the scrub tech handed over the knife.

I had another patient who specifically didn’t want the antibiotic. Antibiotics give her intestinal upset and yeast infections, she said. She understood the benefits, but the risk of a bacterial wound infection in her particular operation was low—about 1 percent—and she was willing to take her chances. Yet giving an antibiotic was so automatic (when we weren’t distracted from it) that we twice nearly infused it into her, despite her objections. The first time was before she went to sleep and she caught the error herself. The second time was after and the checklist caught it. As we went around the room at the pause before the incision, making sure no one had any concerns, the nurse reminded everyone not to give the antibiotic. The anesthesia attending reacted with surprise. She hadn’t been there for the earlier conversation and was about to drip it in.

The third catch involved a woman in her sixties for whom I was doing a neck operation to remove half of her thyroid because of potential cancer. She’d had her share of medical problems and required a purseful of medications to keep them under control. She’d also been a longtime heavy smoker but had quit a
few years before. There seemed to be no significant lingering effects. She could climb two flights of stairs without shortness of breath or chest pain. She looked generally well. Her lungs sounded clear and without wheezes under my stethoscope. The records showed no pulmonary diagnoses. But when she met the anesthesiologist before surgery, she remembered that she’d had trouble breathing after two previous operations and had required oxygen at home for several weeks. In one instance, she’d required a stay in intensive care.

This was a serious concern. The anesthesiologist knew about it, but I didn’t—not until we ran the checklist. When the moment came to raise concerns, the anesthesiologist asked why I wasn’t planning to watch her longer than the usual few hours after day surgery, given her previous respiratory problems.

“What respiratory problems?” I said. The full story came out from there. We made arrangements to keep the patient in the hospital for observation. Moreover, we made plans to give her inhalers during surgery and afterward to prevent breathing problems. They worked beautifully. She never needed extra oxygen at all.

No matter how routine an operation is, the patients never seem to be. But with the checklist in place, we have caught unrecognized drug allergies, equipment problems, confusion about medications, mistakes on labels for biopsy specimens going to pathology. (“No,
that
one is from the right side. This is the one from the left side.”) We’ve made better plans and been better prepared for patients. I am not sure how many important issues would have slipped by us without the checklist and actually caused harm. We were not bereft of defenses. Our usual effort to be vigilant and attentive might have caught some of the
problems. And those we didn’t catch may never have gone on to hurt anyone.

I had one case, however, in which I know for sure the checklist saved my patient’s life. Mr. Hagerman, as we’ll call him, was a fifty-three-year-old father of two and the CEO of a local company, and I had brought him to the operating room to remove his right adrenal gland because of an unusual tumor growing inside it called a pheochromocytoma. Tumors like his pour out dangerous levels of adrenalin and can be difficult to remove. They are also exceedingly rare. But in recent years, I’ve developed alongside my general surgery practice a particular interest and expertise in endocrine surgery. I’ve now removed somewhere around forty adrenal tumors without complication. So when Mr. Hagerman came to see me about this strange mass in his right adrenal gland, I felt quite confident about my ability to help him. There is always a risk of serious complications, I explained—the primary danger occurs when you’re taking the gland off the vena cava, the main vessel returning blood to the heart, because injuring the vena cava can cause life-threatening bleeding. But the likelihood was low, I reassured him.

Once you’re in the operating room, however, you either have a complication or you don’t. And with him I did.

I was doing the operation laparoscopically, freeing the tumor with instruments I observed on a video monitor using a fiberoptic camera we put inside Mr. Hagerman. All was going smoothly. I was able to lift the liver up and out of the way, and underneath I found the soft, tan yellow mass, like the yolk of a hard-boiled egg. I began dissecting it free of the vena cava, and although doing so was painstaking, it didn’t seem unusually difficult. I’d gotten the
tumor mostly separated when I did something I’d never done before: I made a tear in the vena cava.

This is a catastrophe. I might as well have made a hole directly in Mr. Hagerman’s heart. The bleeding that resulted was terrifying. He lost almost his entire volume of blood into his abdomen in about sixty seconds and went into cardiac arrest. I made a huge slashing incision to open his chest and belly as fast and wide as I could. I took his heart in my hand and began compressing it—one-two-three-squeeze, one-two-three-squeeze—to keep his blood flow going to his brain. The resident assisting me held pressure on the vena cava to slow the torrent. But in the grip of my fingers, I could feel the heart emptying out.

I thought it was over, that we’d never get Mr. Hagerman out of the operating room alive, that I had killed him. But we had run the checklist at the start of the case. When we had come to the part where I was supposed to discuss how much blood loss the team should be prepared for, I said, “I don’t expect much blood loss. I’ve never lost more than one hundred cc’s.” I was confident. I was looking forward to this operation. But I added that the tumor was pressed right up against the vena cava and that significant blood loss remained at least a theoretical concern. The nurse took that as a cue to check that four units of packed red cells had been set aside in the blood bank, like they were supposed to be—“just in case,” as she said.

They hadn’t been, it turned out. So the blood bank got the four units ready. And as a result, from this one step alone, the checklist saved my patient’s life.

Just as powerful, though, was the effect that the routine of the checklist—the discipline—had on us. Of all the people in the
room as we started that operation—the anesthesiologist, the nurse anesthetist, the surgery resident, the scrub nurse, the circulating nurse, the medical student—I had worked with only two before, and I knew only the resident well. But as we went around the room introducing ourselves—“Atul Gawande, surgeon.” “Rich Bafford, surgery resident.” “Sue Marchand, nurse”—you could feel the room snapping to attention. We confirmed the patient’s name on his ID bracelet and that we all agreed which adrenal gland was supposed to come out. The anesthesiologist confirmed that he had no critical issues to mention before starting, and so did the nurses. We made sure that the antibiotics were in the patient, a warming blanket was on his body, the inflating boots were on his legs to keep blood clots from developing. We came into the room as strangers. But when the knife hit the skin, we were a team.

As a result, when I made the tear and put disaster upon us, everyone kept their head. The circulating nurse called an alarm for extra personnel and got the blood from the blood bank almost instantly. The anesthesiologist began pouring unit after unit into the patient. Forces were marshaled to bring in the additional equipment I requested, to page the vascular surgeon I wanted, to assist the anesthesiologist with obtaining more intravenous access, to keep the blood bank apprised. And together the team got me—and the patient—precious time. They ended up transfusing more than thirty units of blood into him—he lost three times as much blood as his body contained to begin with. And with our eyes on the monitor tracing his blood pressure and my hand squeezing his heart, it proved enough to keep his circulation going. The vascular surgeon and I had time to work out an effective way to clamp off the vena cava tear. I could feel his heart
begin beating on its own again. We were able to put in sutures and close the hole. And Mr. Hagerman survived.

I cannot pretend he escaped unscathed. The extended period of low blood pressure damaged an optic nerve and left him essentially blind in one eye. He didn’t get off the respirator for days. He was out of work for months. I was crushed by what I had put him through. Though I apologized to him and carried on with my daily routine, it took me a long time to feel right again in surgery. I can’t do an adrenalectomy without thinking of his case, and I suspect that is good. I have even tried refining the operative technique in hopes of coming up with better ways to protect the vena cava and keep anything like his experience from happening again.

But more than this, because of Mr. Hagerman’s operation, I have come to be grateful for what a checklist can do. I do not like to think how much worse the case could have been. I do not like to think about having to walk out to that family waiting area and explain to his wife that her husband had died.

I spoke to Mr. Hagerman not long ago. He had sold his company with great success and was in the process of turning another company around. He was running three days a week. He was even driving.

“I have to watch out for my blind spot, but I can manage,” he said.

He had no bitterness, no anger, and this is remarkable to me. “I count myself lucky just to be alive,” he insisted. I asked him if I could have permission to tell others his story.

“Yes,” he said. “I’d be glad if you did.”

7
“In the 1970s”: S. Gorovitz and A. MacIntyre, “Toward a Theory of Medical Fallibility,”
Journal of Medicine and Philosophy
1 (1976): 51–71.

9
“The first safe medication”: M. Hamilton and E. N. Thompson, “The Role of Blood Pressure Control in Preventing Complications of Hypertension,”
Lancet
1 (1964): 235–39. See also VA Cooperative Study Group, “Effects of Treatment on Morbidity of Hypertension,”
Journal of the American Medical Association
202 (1967): 1028–33.

10
“After that, survival”: R. L. McNamara et al., “Effect of Door-to-Balloon Time on Mortality in Patients with ST-Segment Elevation Myocardial Infarction,”
Journal of the American College of Cardiology
47 (2006): 2180–86.

10
“In 2006”: E. H. Bradley et al., “Strategies for Reducing the Door-to-Balloon Time in Acute Myocardial Infarction,”
New England Journal of Medicine
355 (2006): 2308–20.

10
“Studies have found”: E. A. McGlynn et al., “Rand Research Brief: The First National Report Card on Quality of Health Care in America,” Rand Corporation, 2006.

11
“You see it in the 36 percent increase”: American Bar Association,
Profile of Legal Malpractice Claims, 2004–2007
(Chicago: American Bar Association, 2008).

15
“I read a case report”: M. Thalmann, N. Trampitsch, M. Haberfellner, et al., “Resuscitation in Near Drowning with Extracorporeal Membrane Oxygenation,”
Annals of Thoracic Surgery
72 (2001): 607–8.

21
“The answer that came back”: Further details of the analysis by Marcus Semel, Richard Marshall, and Amy Marston will appear in a forthcoming scientific article.

23
“On any given day”: Society of Critical Care Medicine, Critical Care Statistics in the United States, 2006.

23
“The average stay”: J. E. Zimmerman et al., “Intensive Care Unit Length of Stay: Benchmarking Based on Acute Physiology and Chronic Health Evaluation (APACHE) IV,”
Critical Care Medicine
34 (2006): 2517–29.

23
“Fifteen years ago”: Y. Donchin et al., “A Look into the Nature and Causes of Human Errors in the Intensive Care Unit,”
Critical Care Medicine
23 (1995): 294–300.

24
“There are dangers simply”: N. Vaecker et al., “Bone Resorption Is Induced on the Second Day of Bed Rest: Results of a Controlled, Crossover Trial,”
Journal of Applied Physiology
95 (2003): 977–82.

28
“national statistics show”: Centers for Disease Control, “National Nosocomial Infection Surveillance (NNIS) System Report, 2004, Data Summary from January 1992 through June 2004, Issued October 2004,”
American Journal of Infection Control
32 (2004): 470–85.

28
“Those who survive line infections”: P. Kalfon et al., “Comparison of Silver-Impregnated with Standard Multi-Lumen Central Venous Catheters in Critically Ill Patients,”
Critical Care Medicine
35 (2007): 1032–39.