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Wednesday, February 2, 2011

Airline pilots and NASCAR teams have them: Hospital checklists

Dr. Peter Pronovost's story:

I was a young doctor doing specialty training in critical care, and I was exhausted. Partway through a 36-hour shift at my academic medical center, I was hungry and hadn’t slept for 24 hours, but I was facing an overflowing intensive care unit and somehow needed to discharge five patients to make room for more. Mr. Smith (not his real name), who'd had esophageal surgery [in the gullet], was a borderline call. But because of the pressure I was under, I decided to remove his breathing tube and transfer him to another unit.

That turned out to be a very bad decision. Before long, his breathing sped up as his oxygen levels dropped dangerously. I needed to reinsert his breathing tube. But what I didn't know was that he had severe swelling in his throat. When I looked into his mouth and tried to identify his vocal cords in order to insert the tube, all I saw was a swollen mass of dark pink tissue, like raw hamburger.

I took the instruments out and started to bag him, breathing for him, but he vomited, making that almost impossible. I finally go the tube in – but quickly realized it was in his esophagus, not his airway where it belonged. When you insert a breathing tube, you give the patient medication to stop his breathing. You have about four minutes before he suffers brain damage. It took me between three and five minutes to get the tube properly placed.

I waited anxiously for the medication to wear off, which usually takes about 15 minutes. But after an hour, he was still asleep. After six hours, I was panicked. Luckily, he regained consciousness shortly thereafter and recovered with no ill effects.

Before I pulled that tube, I should have had to complete a checklist that included input from the patient's senior physician and nurse. If anyone had disagreed, I wouldn't have been able to act. Many medical errors occur because hospitals lack standardized checklists for common procedures designed to minimize the chance of bad judgment. Airline pilots and NASCAR teams have them – why don't doctors?

A few years ago, I helped develop just such a list for doctors and nurses in more than 100 ICUs in Michigan. It focused on a common intensive care procedure: inserting a catheter into a vein just outside the heart for delivery of intravenous liquids. It ticked off five steps everyone had to follow, and in 18 months, it lowered the rate of catheter infection by 66% and saved 1,500 lives.

Such checklists are the subject of a bill just introduced to the Massachusetts legislature as Senate Docket #1766/House Docket #879.

Advice: Let your state legislator know you’d like such a law.

Read Paul Levy’s blog post about reducing central line infections through checklists, or read another story about checklists.

Thanks to Joe Kita and Dr. Pronovost for the source story in the October 2010 issue of Readers Digest.

1 comment:

Ed Casey said...

Structured communication saves the day every time. As a supervisor in healthcare, as soon as you rely on a persons memory errors will increase. structured communication but unstrucutured empathy, for the patient.