I was talking to the visionary CEO of a successful Fortune 500 company the other day and she (yes guys, wake up, it is the 21st century!) asked me the following question: "Bill, how come when I fly across country, the pilot-who has been fully certified in the proper procedures required to operate that specific aircraft-still must use a checklist, whereas my doctor may perform a procedure with no specific certification and no checklist?"
"Duh, I dunno!" replied I, unable to come up with a really good explanation. Previously, I would have told her that medicine is not like flying an airplane. It's much more complex and varied, and things like checklists are not applicable. To implement specific certifications for individual procedures would be too complicated, costly and time consuming, I would have said.
But that was before I became a pilot. Recently, I have begun to suspect that the real reason physicians don't have checklists and procedure certification has more to do with differences between the FAA and FDA-and to whom each agency feels it must be ready to answer. As a pilot, I have undergone intensive training, not unlike a medical residency (except the hours are better and the use of simulators for pilot training have really improved the quality, efficiency and safety of the training). Written tests and oral exams for each level of competence (private pilot, instrument rating, commercial pilot, multi-engine, flight instructor, etc.) might correspond to the written medical boards.
But there, the similarity ends. As a potential private pilot, or flight instructor, I must also undergo a practical test in which an FAA-authorized examiner rides in the right seat of the airplane and tries to determine my competence to actually fly the airplane to a well-defined set of standards. Not quite the same as the "see one, do one, teach one" method that still prevails in medical training.
Finally, once certified, I am required to use checklists in operating the airplane. The amazing thing to me is that although I have flown the same airplane for 500 hours, there are times when I find that I may have omitted an item (and only discover my error upon checking the checklist). This occurs even though the checklist for takeoff is very simple-consisting of fewer than 10 steps! Distraction, complacency and maybe boredom all contribute to failing to follow the prescribed procedures. But in an airplane, I am forced to cross-check using the list, so these potential errors are quickly identified and corrected.
At The Johns Hopkins Hospital, we have virtually eliminated bloodstream infections (BSIs) in ICU patients due to indwelling central venous catheters through the implementation of checklists. Doctors placing central lines are required to use the checklist. If they miss a step or fail to follow the checklist procedure properly, the nurse asks the doctor to stop the procedure and correct the error and/or restart the procedure. This change has allowed us to achieve unprecedented results: In the medical ICU, we have gone nine months without a single identifiable BSI attributable to central line contamination!
This transformation was not achieved without pushing the envelope of the medical hierarchy. When we started, one senior Hopkins surgeon allowed as how "no nurse was going to tell his residents how to put in central lines." And even now, I occasionally get reports that nurses are rebuffed by doctors who fail to follow the checklist. My CEO colleague was right when she asked the question. I am convinced that procedure certification and checklists are an important vehicle for improving patient safety-a goal we should all embrace.
Finally, once certified, I am required to use checklists in operating the airplane. The amazing thing to me is that although I have flown the same airplane for 500 hours, there are times when I find that I may have omitted an item (and only discover my error upon checking the checklist). This occurs even though the checklist for takeoff is very simple-consisting of fewer than 10 steps! Distraction, complacency and maybe boredom all contribute to failing to follow the prescribed procedures. But in an airplane, I am forced to cross-check using the list, so these potential errors are quickly identified and corrected.
At The Johns Hopkins Hospital, we have virtually eliminated bloodstream infections (BSIs) in ICU patients due to indwelling central venous catheters through the implementation of checklists. Doctors placing central lines are required to use the checklist. If they miss a step or fail to follow the checklist procedure properly, the nurse asks the doctor to stop the procedure and correct the error and/or restart the procedure. This change has allowed us to achieve unprecedented results: In the medical ICU, we have gone nine months without a single identifiable BSI attributable to central line contamination!
This transformation was not achieved without pushing the envelope of the medical hierarchy. When we started, one senior Hopkins surgeon allowed as how "no nurse was going to tell his residents how to put in central lines." And even now, I occasionally get reports that nurses are rebuffed by doctors who fail to follow the checklist. My CEO colleague was right when she asked the question. I am convinced that procedure certification and checklists are an important vehicle for improving patient safety-a goal we should all embrace.
