so who crashed my cheese?
The January 2009 edition of the British Medical Journal reports on a lecture given by Atul Gawande a surgeon who thinks of medicine asÂ a “test of our ability to manage extreme complexity”
He told the story of Boeingâ€™s long distance bomber, the B-17 Flying Fortress, which made possible the precision bombing of Germany from 1943 to 1945. But the plane nearly didnâ€™t make it into mass production.
Its 1935 demonstration flight to US military chiefs ended in disaster when the air crew forgot to unlock the elevators on the tail. The huge four engine aircraft crashed and burned on take off killing both pilots, their undoubted skills and training unable to save them or the plane.
Today aviation is the leader in the field of minimizing human error, those multitude of small mistakes that can align like so manyÂ slices of Swiss Cheese, opening a tunnel to fulminant catastrophe. And one of the simplest and most effective minimization tools they use is the checklist.
And the field of medicine is beginning to see the benefits of such a easy solution: recently the World Health Organization’s World Alliance for Patient Safety, found that a 19 item perioperative checklist significantly reduced postoperative complications and deaths, and shortly, the WHO will launch a checklist for labour and delivery.
In our own emergency department one potential for error accumulation that we identified involved the variance in our approach to managing a difficult intubation. Everyone was pretty switched in to most intubations, but when things went badly, different people had different management strategies and levels of competence.
In response to thisÂ I (working closely with people a lot smarter than me) developed an intubation checklist (which you can download below) to provide a structured step by step trajectory through the process. We want to land that ET tube. Not crash and burn.
Download: Intubation Checklist (pdf file).
step by step. less haste more speed:
Of course it all feels a little awkward at first. Somebody reading off the steps to the team and ticking them off. And some of the doctors probably felt it a little professionally demeaning.
But what it does do is take the hastiness out of a situation going bad. Everyone moves in the same direction at the same pace and things don’t get missed.
In these times ofÂ high pressure, high workload, low resourced medicine, I think we will see more and more of these sort of tools being developed.Â Areas such as surgery, advanced life support, disaster response, may all begin to look at utilizing check list security. The trick is to keep people using them, even when they think they have it all down pat.
It feels like a storm is brewing.Â Could be a bumpy ride ahead.Â And even though they have probably done it a thousand times over, as I walk up to my flight and glance up, the sight of the pilots running their pre-flight checks gives me that extra sense of security.
Our patients should expect no less.