Monthly Archives: January 2009

1. Make a Checklist. 2. Save Lives.

What’s the value of a checklist, and how detailed does it have to be to provide value? The answer is surprising: a checklist so simple it seems unnecessary can save thousands of lives. Simple checklists consistently applied can pay big dividends.

Why Would You Need a Checklist for Five Steps?

Putting in a central venous catheter can be risky: according to an article in the New Yorker magazine, four percent of them become infected after ten days. That’s eighty thousand people a year in the United States, and five to twenty-eight per cent them die, depending on how sick they are to begin with. Survivors spend an extra week in intensive care.

There are five simple steps a doctor should follow to help prevent infections:

  1. Wash their hands with soap.
  2. Clean the patient’s skin with chlorhexidine antiseptic.
  3. Put sterile drapes over the entire patient.
  4. Wear a sterile mask, hat, gown and gloves.
  5. Put a sterile dressing over the catheter site.

Pretty straightforward. So simple it seems unnecessary to make such a list. Tying your shoes involves more steps, and you don’t have a checklist for that. You could memorize five steps in a minute, and after practicing once or twice you would likely expect never to violate those simple principles of patient safety.

But a one-month study at Johns Hopkins Hospital showed that doctors were skipping at least one of those five steps in one third of the patients they worked on. Johns Hopkins is one of the best hospitals in the world. It is consistently ranked as the very best hospital in the United States, and even there only two-thirds of patients were receiving the full treatment prescribed in a simple five-step checklist. Peter Pronovost ran the study, and set out to see if he could improve the quality of care given by implementing a checklist.

In the first year, following the checklist dropped the rate of ten-day line infection rate from eleven percent to zero. In another fifteen months, only two infections occurred. During the course of the study it’s likely eight lives were saved, and two million dollars. Studies with other simple checklists showed similar results. A similar study run in hospitals across the state of Michigan led to a decrease of infections of sixty-six percent within just three months. By the end of the eighteen month study infection rates at the average ICU in Michigan was better than ninety percent of other hospitals in the U.S. Over the course of the study the Michigan hospitals saved over one hundred seventy-five million dollars, and fifteen hundred lives. Details can be found in a New Yorker Magazine article.

Taking it to England

Now surgeons in England and Wales will be using a pre-surgery checklist to make certain a few small details: Is this the right patient? Is this the right limb? Has the patient had the right drugs? And sixteen others. Just taking these basic precautions is expected to save hundreds of lives annually and cut down complications dramatically. In a trial run, the checklist reduced the death rate following surgery from 1.5 per cent to 0.8 percent.

Simple and Effective

A checklist can be valuable in several ways. First, just by creating it you force your team to consider what the right thing to do is. (Hint — if you can’t agree on the steps in the checklist, you have a bigger problem to deal with) Second, you create a standard that everyone is expected to follow. Putting it in writing emphasizes that. Third, you provide a reminder to those who, caught up in the moment, might need help to remember all the steps.

Checklists can be applied in almost any field. Pilots use them all the time: before taking off, before landing, etc. Lawyers use checklists to help decide the legality or illegality of something. Shopping lists and recipes are checklists. There are whole web sites devoted to checklists.

So follow this simple checklist to get started:

  1. Pick a procedure to make a checklist for. Be sure to pick a simple one for your first time.
  2. Define the checklist.
  3. Decide how you will track compliance.
  4. Decide when you will re-examine the procedure, the checklist, and the compliance stats to improve the checklist’s effectiveness.

You see what I did there?


Vitamin C is a Chemical

Ignorance is frustrating. Here’s an article about the camu camu fruit touting the benefits of “Natural (not synthetic)” vitamin C.

Vitamin C is a chemical. There’s no way around it. Here’s the wikipedia article on Vitamin C, which lists the chemical formula and shows a picture of the structure. As a chemical, there is no difference between “natural” and “synthetic” vitamin C; they both have the chemical formula C6H8O6 . They might be talking about the beneficial effect of the chemicals that come along with the vitamin C found in the camu camu, but that has nothing to do with whether the vitamin C itself is natural or synthetic.

By the way, camu camu is actually second on the list of fruits with high vitamin C content. The kakadu plum is up to 5% vitamin C by weight.