Last Updated on Wednesday, 09 May 2012 12:59
Sometimes It's difficult to introduce the need of a checklist. At the end, it's a simple list of steps.
The greatest sin is the question: How can I forget X?
So, the real mistake is when we fail to recognize that we use to forget a step in any procedure.
I've read this very inspirational article The Checklist, by Atul Gawande about the need of checklists in medicine. Some excerpts:
An investigation revealed that nothing mechanical had gone wrong. The crash had been due to “pilot error,” the report said. Substantially more complex than previous aircraft, the new plane required the pilot to attend to the four engines, a retractable landing gear, new wing flaps, electric trim tabs that needed adjustment to maintain control at different airspeeds, and constant-speed propellers whose pitch had to be regulated with hydraulic controls, among other features. While doing all this, Hill had forgotten to release a new locking mechanism on the elevator and rudder controls. The Boeing model was deemed, as a newspaper put it, “too much airplane for one man to fly.” The Army Air Corps declared Douglas’s smaller design the winner. Boeing nearly went bankrupt.
Still, the Army purchased a few aircraft from Boeing as test planes, and some insiders remained convinced that the aircraft was flyable. So a group of test pilots got together and considered what to do.
They could have required Model 299 pilots to undergo more training. But it was hard to imagine having more experience and expertise than Major Hill, who had been the U.S. Army Air Corps’ chief of flight testing. Instead, they came up with an ingeniously simple approach: they created a pilot’s checklist ...
Medicine today has entered its B-17 phase. Substantial parts of what hospitals do—most notably, intensive care—are now too complex for clinicians to carry them out reliably from memory alone. I.C.U. life support has become too much medicine for one person to fly.
On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. Doctors are supposed to
(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, and
(5) put a sterile dressing over the catheter site once the line is in.Check, check, check, check, check.
In December, 2006, the Keystone Initiative published its findings ... The typical I.C.U.—including the ones at Sinai-Grace Hospital—cut its quarterly infection rate to zero.