David Goggins
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International Poker Champion
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Former CIA Clandestine Operative
Chris Hadfield
Retired Canadian Astronaut & Author
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Checking Our Costliest Errors

Question: Why are checklists important?

Atul Gawande: Yeah, I mean, I wrote a whole book on checklists. You'd be -- you know, why in the world would anybody write a whole book on checklists? And it was the last thing I thought I would be writing about. But I've been fascinated by how we grapple with risk and complexity in medicine, and I got assigned a project to try to find a way to reduce deaths in surgery. We have been struggling with our performance, and so I started looking at how people in other fields grapple with the enormously increasing complexity that people in professional worlds are dealing with. And what I found was -- in aviation, in skyscraper building and other lines of work -- that there was something really fundamental going on; we had transformed from a world where ignorance was our biggest struggle as human beings -- this is the way it was for millennia; we didn't understand why the human body fails, how to build things really well, how to do many, many kinds of tasks in the right way; that knowledge was missing.

Today, however, our biggest struggle is with what people call ineptitude, meaning the knowledge is there, but somebody's not doing it right. And in surgery, in other parts of medicine, what we're finding is that the amount of knowledge, the volume, the complexity, the tons of papers coming across the transom, the technologies that are proliferating -- that all of it has exceeded our abilities as individuals to hold it all in our head and do it right. And there are lots of fields, it turns out, where this has been happening: constructing buildings well, making good investment decisions with our hedge funds. And when I looked to see how people who actually are solving these problems were solving it, I thought you'd find that they had just trained in a different way, or they were training longer and harder, or they had a different kind of use of technology. Instead, what I found over and over again was, they used checklists, as simple and mundane as it sounds; that the checklists in a way filled in for weaknesses in people's brains, things that they forgot. It also filled in for weaknesses in making teams work. Teams constantly drop stuff between the cracks, and so we made a checklist based on what I learned. Actually, I got folks from Boeing to help us out. How do you make a checklist? I didn't think that that would be all that hard. It turned out to be hard.

And one of the things they showed us was how to really focus on making it swift and usable. We made a two-minute surgery checklist; it had just 19 items. Some of them were just make sure you don't forget dumb stuff: make sure you gave antibiotics, make sure you have blood ready for a high-blood-loss case. And then there were other interesting parts: make sure everybody in the room has been introduced by name and role; make sure the surgeon actually explained to the team what their goals for the operation are; make sure the anesthesiologist and nurses had a chance to explain their plans for the operation. We put that checklist in eight hospitals around the world, ranging from rural Tanzania to Toronto and Seattle, and every single hospital we put it in had a double-digit reduction in complications. The average reduction in death was 46 percent. That made me realize there was something much deeper and more important going on here about this set of problems we're grappling with in the modern world.

Question: What percentage of American hospitals currently employ a checklist system?

Atul Gawande: Well, on the one hand, you'd say zero percent. When you look at -- we have about 13,000 diagnoses we've recognized the human body to have. We have 6,000 drugs, 4,000 different kinds of medical and surgical procedures, and we know for each of them there's anywhere from half a dozen to many dozen steps that we should make sure are done correctly. And we just rely on human memory, the person in the office that you go to, to just remember what that stuff is. And we drop stuff all the time. A friend of mine went in for depression; she was just becoming really low. The doctor put her on an antidepressant, and for the next three years they're changing antidepressants, trying to get it right. And it was only much later, three years, that they realized, oh, we didn't check your thyroid hormone level. And she just had low thyroid hormone levels. Two weeks of thyroid hormone and she was better. She lost three years because of that.

So the surgery checklist is in place in about 20 percent of American hospitals. Some countries have implemented it nationwide; France, the United Kingdom, places like Ecuador are adopting it nationwide. But are people really using it? In their heart of hearts, are they in there? Well, in the surgery world we are adopting it. But have we recognized the lesson that maybe this is the way we ought to think about -- that we ought to have -- literally pick up a checklist when you come in with a new problem? That we're not there with. Every time you get on an airplane, someone picks up a checklist.

Question: Are there any institutional obstacles in hospitals adopting this?

Atul Gawande: Well, there are -- there's a cultural obstacle: we see checklists as a weakness as individual practitioners. You know, if you were in seeing a surgeon, and they said, hmm, I'd better check a textbook on this, or I want to check my checklist -- we're not there yet culturally. We're starting to be. The second obstacle is, any old checklist is not the story here. I mean, we could end up just creating a bunch of paper work and tick boxes that just get ignored and aren't really valuable. So the institutional obstacle is, we have to recognize this is science. In the aviation world we have a National Transportation Safety Board that goes in and investigates accidents and shows the lessons that a Boeing or an Airbus then can adopt into checklists, into making the lessons usable. We need the same thing, a kind of medical safety board -- a national institute for health systems innovation is what I would call it -- that would recognize for being discharge to go home from the hospital, there are six key components to a checklist that every hospital should have that we know make a difference in reducing the likelihood that you're going to bounce back into the hospital. We print two-inch-thick guidelines saying what you should do for cardiac care. But we haven't boiled it down to here are the six things one should never forget when you're in there with that patient complaining of chest pain.

The biggest challenge in our world is not lack of knowledge, but an inherent ineptitude at utilizing a vast and unprecedented web of data. From medicine to architecture to finance, the most effective way to organize and act on such complex knowledge may be something as simple as a well-enforced checklist.

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