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Book Review

     Spring 2010



      The Checklist Manifesto-How To Get Things Right
        By Atul Gawande
        Metropolitan Books, Henry Holt and Co., New York, pp. 209, 2009

      In 1999 the U.S. Institute of Medicine, part of the federal health beauracrcy, issued a startling statistic. As
       many as 98,000 deaths of hospitalized patients annually were caused by medication errors. And this does
       not take into account all the surgical errors (e.g. operating on the wrong extremity or patient) and
       preventable complications (e.g. nosocomial infections) that lead to extended hospital stays or death. One
       must think of the old adage: hospitals are indeed dangerous places.

       Now Dr. Gawande, surgeon and best-selling author of books and magazine articles, has written a new book
       with a modest proposal. Something as simple as a checklist may offer the ounce of prevention that is worth
       the pound of cure. Citing the example of the aviation industry and pilots reliance on such lists to take off, fly
       to their destination and land safely, he asks why such a solution can't be used in complex procedures in
       medicine. So much of modern medicine requires multiple physicians and health care specialists that there is
       simply too much to remember, especially considering that each patient represents both common and unique
       challenges.

       Of course some form of checklist has been used traditionally in medicine. For example the so-called sliding
       scale for administration of insulin doses to diabetic patients based on the blood glucose level; or the amount
       of potassium to be administered in cases of hypokalemia; or the step-wise procedure of checking blood
       product administration before transfusion. And many hospitals have now instituted a checklist for pre-
       operative evaluation of the surgical patient (a so-called "time-out"): right patient, correct body part to be
       operated on, listing of allergies and complicating diseases that may be potential threats, correct imaging
       studies to be reviewed in the operating room, all necessary equipment for the surgical procedure and
       common emergencies on hand and ready for use. These are only a few steps that may be required in
       complicated cases.

       Dr. Gawande spent considerable time investigating how other industries utilized checklists to manage complex
       tasks. He consulted the chief engineer of a new 32 story addition to his own hospital and got a "hard hat"
       tour of the facility at its half-way point in construction. Noteworthy were two extensive checklists in the
       construction management office: one for the myriad standard items and sequence for building a modern
       complex hospital building; and the other for potential problems that might arise. He points out the virtues
       of specialization and sub-specialization and most of all the necessity of communication between the
       specialists to solve potential problems, in this case a buckling of one of the floors in the building. He also
       visited the kitchen of an upscale restaurant to discover how all the intricate details of gourmet food
       preparation for 150-300 people a night is managed by detailed checklists called recipes and the menu and
       by specialists talking to each other.

      This is a rather short book but its major concepts are skillfully presented with apposite examples and an
      easygoing style of writing. Even the medical problems are discussed with clarity and occasional wit. Borrowing
      heavily from the checklist pattern of the aviation industry, Dr. Gawande and colleagues launched a World
      Health Agency worldwide study of surgical procedures utilizing a key 19 item checklist. The list was
      consolidated to include the most important items, following the old adage that less is more, in pre, intra and
      post-operative care. They found a significant reduction in operative complications in hospitals in both
      developed (including the U.S.) and developing nations despite the latter's lack of high tech equipment.

      In addition to the checklist avoiding crucial errors, the author also claims that it encourages a spirit of
      teamwork among the participants in an operation: surgeon, anesthesiologist, scrub and circulating nurses and
      technical personnel. Any member of the team may feel comfortable raising questions or problems without fear
      of incurring the surgeon's wrath.

An informative book that reminds us that even in highly technical fields, sometimes simple solutions are the
the best.

      Arthur H. Weintraub, MD

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