Simple ticks can save lives
Medical knowledge is worth nothing unless it is correctly implemented in real health settings and checklists have emerged as a simple but effective way of ensuring every step is completed. Here is my Medical Independent column from 9 May 2013.
The inquest into the death of Savita Halapanavar in Galway University hospital found a number of lapses in care. According to expert witness obstetrician Dr Peter Boylan, these did not directly contribute to her death. One of the lapses of care identified was that her vital signs were not monitored every four hours in the days before her death.
Monitoring the four vital signs – pulse, temperature, blood pressure and respiratory function – is hospital policy for women like Savita, who was at risk of infection due to the rupturing of her membranes on Sunday, the day of her admission. There were particularly long gaps identified in monitoring her vital signs on Tuesday – the day before she became critically ill. Scientific literature shows that missing just one vital sign can be fatal.
Medical science is increasingly complex and one of the many challenges is how complex care can be managed by a myriad of different professionals simply and effectively. In this instance, how can one ensure that all vitals are monitored regularly when required? The answer is a check-list.
The use of checklists is an application of the knowledge of airline safety, which has been in use since the pilot’s checklist was developed during World War II, to medical care.
Mr Atul Gawande, a general surgeon and Harvard professor, has written a page-turning best seller on the application of checklists to surgical safety. Mr Gawande, Director of the WHO’s Global Challenge for Safer Surgical Care, writes about the reasons people fail. The first reason given is ignorance, the second is ineptitude, i.e. the knowledge exists but we fail to apply it.
In ‘The Checklist Manifesto: How to Get Things Right’, Mr Gawande observes how medicine has developed so much that ineptitude is now as much of a struggle as ignorance. “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,” he maintains.
Checklists are a way to make sure that we always apply the knowledge we have in the correct way. Their application to surgical outcomes over the last 12 years has been remarkable. Thousands, may-be hundreds of thousands, of lives have been saved, the rate of post-operative infection has been radically reduced, lengths of stay have been halved, and outcomes have been manifestly improved. Clinical studies have found that surgical deaths are reduced by 50 per cent and surgical complications are reduced by more than one-third when the surgical checklist is implemented.
Central to the success of the surgical checklist is that nurses are expected and empowered to point out to doctors when a checklist is not being adhered to. Hospital administrators have bought into them, literally, because check-lists have huge benefits on the bottom line. Yet, surgical checklists are a relatively new science – it is only since 2006 have medical journals begun to report on the success stories of surgical checklists.
In 2008, the WHO published the safe surgery checklist. This has been embraced in Ireland by the HSE, RCSI and other key groups such as the Irish Midwives and Nurses Organisation (IMNO). A survey in 2010 carried out by the IMNO found that 75 per cent of respondents said the safe surgery checklist was a part of operating room policy in their hospital, but only 50 per cent said that it has been implemented in its entirety.
Checklists work because they remind people what to do, as well as setting out the required minimum steps in any process. This in turn leads to more consistent and higher standards of care. However, all checklists, be they for vitals or for surgery, are only as good as their implementation. In times of greater pressures on fewer staff who are expected to provide more complex care, checklists are more necessary than ever.
It is time to ensure that basic systems such as the four-hour monitoring of vital signs and the safe surgical checklists are adhered to in all Irish hospitals. As Mr Gawande remarks, failure from ignorance is forgivable, but failure from ineptitude is not.
For more on surgical safety and related topics see www.gawande.com.