Saving 28,000 Lives a Year 263
The New Yorker is running a piece by Atul Gawande that starts by describing the everyday miracles that can be achieved in a modern medical intensive care unit, and ends by making a case for a simple and inexpensive way to save 28,000 lives per year in US ICUs, at a one-time cost of a few million dollars. This medical miracle is the checklist. Gawande details how modern medicine has spiraled into complexity beyond any person's ability to track — and nowhere more so than in the ICU. "A decade ago, Israeli scientists published a study in which engineers observed patient care in ICUs for twenty-four-hour stretches. They found that the average patient required a hundred and seventy-eight individual actions per day, ranging from administering a drug to suctioning the lungs, and every one of them posed risks. Remarkably, the nurses and doctors were observed to make an error in just one per cent of these actions — but that still amounted to an average of two errors a day with every patient. Intensive care succeeds only when we hold the odds of doing harm low enough for the odds of doing good to prevail. This is hard." The article goes on to profile a doctor named Peter Pronovost, who has extensively studied the ability of the simplest of complexity tamers — the checklist — to save lives in the ICU setting. Pronovost oversaw the introduction of checklists in the ICUs in hospitals across Michigan, and the result was a thousand lives saved in a year. That would translate to 28,000 per year if scaled nationwide, and Pronovost estimates the cost of doing that at $3 million.
The Greek god Nike said: (Score:5, Funny)
JUST DO IT!
Yes, and it's called LifeWings (Score:5, Interesting)
Pilots come and give talks in hospitals about how checklists significantly reduced air crashes in the USA, which it has.
I saw this presentation at my hospital, but I'm not exactly sure if it is applicable it medicine.
Re:Yes, and it's called LifeWings (Score:4, Interesting)
There is a hopeless lack of process in the medical industry. They need a good solid dose of ISO9001 or CMMI.
Re:Yes, and it's called LifeWings (Score:5, Insightful)
There is a hopeless lack of process in the medical industry. They need a good solid dose of ISO9001 or CMMI.
Or simply more nurses.
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Re:Yes, and it's called LifeWings (Score:5, Insightful)
Nah. Mostly we could even do with worse ones. Many of the tasks of a nurse don't require special training. (Like handing that glas of water to the woman that can't reach it, making sure that guy doesnt faint on his way to the toilet and falls to the floor out of reach of the alarm button.) On the other hand, a ringing buzzer may also be a sign of an emergency. So every buzz (service and alarm are indistinguishable) has to be answered as soon as possible.
So for five simultanious alarms, you need five people, not a single better one.
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Yup, I was a medic in the Air Force. In military medicine (at least Air Force hospitals), the medics (EMT/LPN licensed) out number RN nurses about 5 to 1. Also, due to reduced personal liability (military won't hang you out to dry to lawyers, except in cases of obvious dereliction of duty), they pushed many tasks that civilian RN's are require for, onto the techs. And things were rather well run, when I was in ('89-'93). Even in the VA hospitals I worked in (part of OJT), things seemed to be doing pretty we
The VA system isn't broken, it's ignored. (Score:3, Insightful)
I don't know if the system's broken down or is just being mis-managed but at one time, I preferred military care over civilian.
The military/VA care process is still better organized and more streamlined than the horrendous kludge of the private system, but it's also under a remarkable strain from a flood of war casualties and the rapidly-aging population of Vietnam vets. Ironically, the VA system provides better, cheaper care because it does not suffer from many of the inefficiencies of a market-based heal
Re:The VA system isn't broken, it's ignored. (Score:4, Insightful)
Ironically, the VA system provides better, cheaper care because it does not suffer from many of the inefficiencies of a market-based health care system-- preventive care and unified standards within a single provider make treatment much more effective and cheaper in the long run.
When I was a medic, I asked a doc what his opinion was of socialized medicine (had just read article about Canada's system). He said: Look around. I prefer being a military doctor. I make less, but then I don't have to worry about business expenses. personal insurance, and having insurance companies looking over my shoulder when I'm working with a customer.
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You apparently have no fscking idea what a nurse does.
One of best predictors of whether or not you survive your hospital stay is the quality of nursing care. [nih.gov]
Nurses are responsible for infection control, for monitoring and record keeping of vital signs and other diagnostic data, and for administering medication. They are often the primary providers of patient education, and are often the ones who keep
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Uh, no.
It is true that more doctors are specializing rather than going into primary care. This has nothing to do with the roles of doctors and nurses.
If a person thinks this, then that person has no idea what a nurse does. Nurses have been gi
Re:Yes, and it's called LifeWings (Score:4, Informative)
I'm sorry, you're right.
"worse" was the wrong word. "less qualified in the actual medical stuff"
Nurse support staff, as the other poster named ist.
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In this case I don't give a shit about moderation: Fuck you!
Kind of all people in medical care is awesome. They are nice people, well educated, work their ass of and don't get paid what they deserve but love people so they carry on. To blame them is so wrong in so many levels.
Grand parent was right, sure their procedures could improve but in the end bad things happen if there are to few people around to finish all the tasks.
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The health care industry has its share of bad apples, just like any other barrel.
There will be disinterested nurses and doctors, as well as plain stupid ones. And their will be highly interested and skilled ones too.
This problem can be attacked in many ways. The way that Mr. Provonost wants i
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The issue is that proper SCIENCE has little room for heroes. If science and engineering is performed correctly and documented, you catch mistakes before they cause problems. 90%+ of all things treated at the hospital have a regimented treatment laid out by mountains of research.. the trouble is matching the proper research to the problem, then executing the treatment exactly as the research was proofed.
Your example is exactly the kind of non-engineer thinking that needs to stop. Somebody, has generally alr
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Let the highly skilled people make more decisions, and defend them when they do so, by making it illegal to sue hospitals for trying to help you -- only for lack of trying. As it is today, if a doctor has a choice between a procedure that slightly improves 70% of the patients and does nothing for the rest, or one that cures 95% and maims 5%, he will almost always have to go for the former, cause the 5% unlucky ones will sue.
Not far enough. The whole tort system needs to be altered to stop paying out money just because something bad happened. The way it used to work, and should work, was that your lawsuit only had merit if you could show the doctor was wrong to choose the 95%-success course of action. If he was, the wrong decision or negligence or whatever is punished. There used to be consideration of what a reasonable (competent in the field) person (doctor) would have done. Not anymore.
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The point of checklists is not to stifle creativity, it is to bolster memory and stifle mistakes.
If you look at the checklist, think about it, and decide to not do one of the steps or do that step differently, that's innovation. It may have a good result or a bad result, and your reward or punishment will depend on the result. But it was intentional. If you make an intentional choice and the result is good, you can change the checklist.
If you don't have a checklist, and you forget an important step
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no, even the best people WILL make mistakes even if they're just small ones. That's the whole point of things like ISO or QS that somebody ELSE is looking for those mistakes. Imagine if GM made one mistake per worker, and they allowed 2 mistakes per Auto off the line... oh, wait that happened and they nearly died. 1 mistake per worker each day is intolerably high in a world class environment.. and Nurses and Doctors are all Bachelors degree or higher, that's the top 15% of all workers already. You don't g
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Says the guy who can't stand for who he is and has never talked to his colleges at work.
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They need a good solid dose of ISO9001 or CMMI
Yes man, I hope you get your dose of CMMI medical treatment.
It will be a most morbidly hilarious thing.
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When we had our baby, it was against hospital policy to have visitors stay the night.
Re:Yes, and it's called LifeWings (Score:4, Insightful)
After becoming a pilot, I became a firm believer in checklists and brought them into my computer work. I make checklists for software delivery processes, framework installations, toner cartridge changes, etc. Then I ask someone else in the team to carry them out while I watch over their shoulder. And then I make improvements and put them in a well-known directory. My vacations are never interrupted anymore. ;-)
Devon
At $107 per life... (Score:3, Interesting)
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I don't know about that. There are some people I know who I'd pay at least that much to get rid of.
Re:At $107 per life... (Score:5, Interesting)
While I'm a firm believer in checklists, I have my doubts about the study. It sounds to me like this might have been conducted by a guy who has a bias toward having checklists (which I do too).
It'd be difficult to measure how many lives were saved by the checklist (as opposed to other factors). I bet he looked at the deaths, and then looked for mistakes in procedures (that could have been avoided with a checklist).
But there are some serious issues with this methodology. Were these patients going to die of something else? Would the checklist have prevented the mistake? And how many patients inadvertently lived due to mistakes that would have died, had checklist procedures been followed?
This message was posted in Slashdot tradition - without reading the article.
Re:At $107 per life... (Score:5, Informative)
Yes the methodology is important - and in this case the article is a fascinating read - basically he compared the number of mistakes beforehand and afterwards, but also looked at the correlation with the number of deaths before hand and afterwards.
In this case the causes are a known problem (especially line infections) and they could directly correlate the adoption of checklists with a drop in the incidence of line infections, and subsequently with a lower death rate. Seems like fair enough science to me, and logical as well :-)
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............. It'd be difficult to measure how many lives were saved by the checklist (as opposed to other factors). I bet he looked at the deaths, and then looked for mistakes in procedures (that could have been avoided with a checklist). ................
I'm not sure if your getting the point of the article.
The article explains that in the "ICU" the technology exists to save people who would normally have no chance, If and only if, the proper procedures are carried out.
One person or a piece equipment not being available at the right time could be the difference of a patient living or dying.
With a checklist care can given in a consistent and methodical manner.
Towards the end of the article it talks about the little Austrian girl and that prev
Why it's not done (Score:3, Interesting)
The changes need to be made at the FDA, then health care will improve.
Get rid of the dinosaurs (Score:3, Informative)
They reflexively cry out against 'cookbook' medicine and 'socialized medicine' while ignoring sound scientific advice.
We really do need an attitude change here in the same way that Detroit needs an attitude change. (Throw the dinosaurs out.)
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Having been both a medic and a programmer, I can tell you that "basic proven work flow improvements" are not one-size-fits-all.
Re:Get rid of the dinosaurs (Score:5, Informative)
Huh? WTF has concerns about cookbook medicine to do with the need for universal access to health care? I am one of those physicians who reflexively cries out FOR universal health insurance. Of course I don't call that 'socialized medicine' because its not different than our 'socialized' school, EMS, Fire, Police, and Highway systems to name a few.
And while I think that there are a lot of potential problems with 'cookbook medicine' there are also a lot of potential benefits. Its like any tool that can be used to help or hinder the practice of medicine. For example, an EMR that reminds me my diabetic patient is overdue for annual eye screen and should be on an ACE-Inhibitor is a great idea. However if the same system forces my hand on the ACE-I when I know that patient has had multiple episodes of fainting due to low blood pressure (which an ACE-I would exacerbate) its a problem. Similarly, if I spend all my time inputting data into the EMR it becomes more of a hindrance than a help.
In the case of ICU checklists, nurses every year are required to do more and more documentation (an average of 18 pieces of paper for a new non-ICU admission to my hospital) and every checklist or additional page you add to that is taking time away from patient care. So what sounds like a great idea may in fact cause worse outcomes because it puts the nurses focus on a paper rather than their patient.
Of course what I always find to be funny is the very same people who have zero tolerance for any risk or error and decry doctors for an untoward fear of cookbook medicine are the first ones to ask you to depart from standard practice for their personal special case... the antibiotics they want for a virus, the expensive lab test or MRI that is really not necessary, the pricey new drug on TV they want when a safer older drug with a proven track record works just as well. That innate lack of trust of health care providers and assumption of laziness or ill will translates to their own relationships with their physician in different but recognizable ways.
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For example, an EMR that reminds me my diabetic patient is overdue for annual eye screen and should be on an ACE-Inhibitor is a great idea.
For the non-medical people out there: EMR = Electronic Medical Record
Of course what I always find to be funny is the very same people who have zero tolerance for any risk or error and decry doctors for an untoward fear of cookbook medicine are the first ones to ask you to depart from standard practice for their personal special case...
I'm finding this to be a more common practice of patients for a variety of reasons, but the problem is often compounded by the doctors not listening to the patient's concerns. I'm not saying that doctors don't have the patient's best interests at heart, but most patients find it difficult to establish that rapport where they can rule out the doctor is being "lazy" or even downright "evil" unless the doctor is able to spend time with them
Re:Get rid of the dinosaurs (Score:5, Interesting)
It's amazing how resistant 'modern' medicine is to basic proven work flow improvements such as checklists, treatment guidelines.
It's not just modern medicine - this has been a problem since more-or-less forever. Go and look up a little medical history about the early use of antiseptics, anaesthetics and even such basic practices as good hygiene.
There was a documentary shown a few weeks ago in the UK about a 19th century doctor who noticed that births attended by doctors had a much higher fatality rate than those attended by midwives - he eventually figured out that hygiene had something to do with it and started making sure he and those working under him washed before visiting the maternity wards. His fatality rate plummeted but still the majority of doctors refused to change how they worked and he wound up literally driven insane because he had worked out how one could easily save thousands of lives but nobody was prepared to even give his idea a go.
Unfortunately I forget his name now so I can't easily find more information to point you at.
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Probably Semmelweis [wikipedia.org].
Yep, that's the one. Thanks.
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Not to mention the indefensible batshit insane hours many medical personnel pull.
In the Air Force, it is generally forbidden to work technicians beyond a twelve-hour shift except in contingency (wartime) ops. Performance, even by experienced people working with GOOD checklists turn to shit quickly after 12 hours. That's why the USAF is manned to support 2 x 12 hr shifts in most cases. Crashed aircraft cost missions, money, and lives.
OTOH, one reads of thirty hour shifts in the medical world. Sorry, that's n
Look at Airplanes (Score:4, Interesting)
They use checklists for everything, and flying a plane is much less dangerous than operating on someone in an ICU.
Don't they already have some kinds of checklists for "make sure we don't leave any sponges or scalpels in the patient."
Re:Look at Airplanes (Score:5, Interesting)
Aviation checklist users suffer from a condition that I'll call "known-data blindness" for lack of a better term.
I've run the C-172M checklist several hundred times, and let me tell you, it's *very* easy to lose track of your place in the list, and forget whether your memory of having completed a given item is from this evening's flight, or from the one you did this morning.
This is almost never deadly in a beast as simple as a fixed-prop, fixed-gear Cessna 172. Come to think of it, I've *never* caught a condition with my checklist that would have killed me, had I missed that item.
My personal experience leaves me wondering if it's possible that checklists could cause obvious things to be *missed*.
The problem could be easily fixed with dynamically generated checklists that cannot be answered without having read and comprehended the question... but that would slow things down so much that I bet it would cost more lives than it would save.
Re:Look at Airplanes (Score:5, Insightful)
In my experience with rocket engine tests, both professionally and as a hobby, I've seen checklists be invaluable tools. I've seen them catch problems that were irrelevant, ones that would have resulted in loss of data, ones that would have resulted in incorrect operation, and ones that had direct safety impacts. However, the problem you describe is very, very common. The simplest solution is quite effective, and they discuss it in the article (but fail to mention how amazingly important it is). You need the person who is responsible for reading the list and making sure each item happens to *not* be the one doing it.
In the article, the nurses follow the checklist and stop the doctors if a step gets missed. At an XCOR Aerospace rocket test, at any given time there is someone whose sole responsibility is reading the checklist (who that is may change through the day, but there always is such a person, and who it is is always clearly defined). In both cases, the person with the checklist has the authority to stop whatever is happening and correct the situation. When I test my hobby rocket motors, the test crew is much more limited (usually two or three people, compared to at least six and often many more at XCOR). As a result, the person reading the checklist is usually also doing things on it. Mistakes are more common, and it's not uncommon to set down the checklist and just do things for a while.
That separation of roles is simple, yet highly effective. Obviously it's a bit hard in a single-pilot airplane. But, in a situation where it's at all possible, it's well worth doing. There are a number of reasons it helps, but one of the simplest is important: the reader can hold the checklist binder with their thumb pointing at the last step completed, since they don't have to use that hand to actually do anything. In the medical case, you're actually making checks on a piece of paper that goes into the file, but the idea is the same.
As an aside, having the checklist be unfamiliar is a bad thing -- mistakes and confusion are much more common after a checklist change. The fix lies in how you use the checklist, not what it says. The reaction to hearing the next step on the list read needs to be "yep, I've already got the tools in my hand" or "oh, right, nearly forgot that" -- not "wait, what was that? Oh, right I was already doing that." If you do that, people will be more inclined to ignore the checklists, because they interfere with operations.
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Thanks for that. Apparently I skimmed the article a little too quickly. Imagining myself in both positions in the cockpit, I'm inclined to agree. Steps would rarely get missed or performed incorrectly. A far superior system to what I've been doing.
I wonder if delegating checklist-reading to a non-pilot passenger would fall under "good crew-resource management" or "gross negligence".
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I've run the C-172M checklist several hundred times, and let me tell you, it's *very* easy to lose track of your place in the list, and forget whether your memory of having completed a given item is from this evening's flight, or from the one you did this morning.
That is a problem, but it's much less likely that you'll fall for it when you're working to the checklist, rather than trying to remember what you need to check also. 'Are the tyres OK? I'm sure they were'...
I've *never* caught a condition with my checklist that would have killed me, had I missed that item.
No, but does that mean you don't need to do it? I went through the checklist one time before a flight and discovered no fire extinguisher on board - I didn't need it, as it happens. But the reason it wasn't there was that the engine had caught fire the previous week, and they'd used it. You can be damn
Re:Look at Airplanes (Score:5, Interesting)
The medical staff was supposed to log all interactions, which range from medicines administered to having a conversation with the patient or parent/guardian. Everything was to be logged, so that nothing was forgotten. And nothing could ever be deleted, by design.
Well, people made mistakes (the nerve of them!), and sometimes a record would be entered on the wrong patient, and you'd really WANT to delete that misleading information. This spawned numerous debates as to whether the we should really remove the erroneous information, or mark it as bad information. For instance, if Note 5 was that a certain drug was administered, and a Doctor relied on Note 5's misinformation to do whatever was done in Note 6, by deleting Note 5, you remove the defense and rationale of the Doctor.
Likewise, if you allow temporary removal of a note, then you allow someone to "undelete", you could end up in a similarly indefensible position. Note 5 correctly says that full dosage was administered at 10PM. Note 5 gets inadvertently deleted (recycle bin). At 10:05, a nurse sees that no dosage has been administered, so administers another full dosage, and logs it as Note 6. Someone undeletes Note 5, and makes the nurse look incompetent. Patient dies. Nurse got framed. All bad.
After all these discussions, at the direction of the administration, we built a permanent delete function, so that these erroneous notes could be permanently removed. No "recycle bin". Heavy logging of what transpired and when. And an alert window warning the user that they are about to perform an irreversible action of delete.
So we made the warning bigger and longer and wordier. And the rate of calls to undelete something went UP.
Finally we changed the alert box to prompt the user to do something different. In order to complete the Delete function, the user had to key in the word "irreversible" into the alert prompt.
Requests to undelete went down to near-zero.
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This spawned numerous debates as to whether the we should really remove the erroneous information, or mark it as bad information.
No mark as bad and refer to replacement note option?
That's why they call it a check list (Score:3, Insightful)
If you actually check off the items on the list and not just look at them, you don't need your memory to tell you whether you've done them or not, you can just look at the check marks.
The other half of the equation is taking the check list seriously in the first place. If you do that, then you WILL read and comprehend the questions.
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I've run the C-172M checklist several hundred times, and let me tell you, it's *very* easy to lose track of your place in the list, and forget whether your memory of having completed a given item is from this evening's flight, or from the one you did this morning.
Try reading the list out loud. This helps me for some reason.
Devon
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Your problem is not with the checklist per se, but the implementation. A printed sheet that doesn't get marked off is merely a mnemonic, not a checklist. If you don't actually check each one off, for example with a pen* or a checkbox on a pda, then you're just using a physical mnemonic, and it's just as fallible as a mental one.
Justin.
* perhaps on a wipeclean overlay?
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In my aviation experience, if you are ever interrupted in a checklist, or unsure of where you are for some reason, then you restart the from the beginning. This forces you to be conscious of the checklist as you run through it, instead of working completely off of a muscle memory and running through the entire thing in a haze.
Not that this behaviour is entirely bad, in fact it's even sometimes desirable. It's exactly the reason why emergency checklists should be so thoroughly memorized: in a high stress si
Look at Suction. (Score:2)
"Don't they already have some kinds of checklists for "make sure we don't leave any sponges or scalpels in the patient.""
Corsec67, I'm sorry to tell you but we left a nurse inside you.
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please mod parent up under the RTFA Funny tag.. oh wait...
yes i know it was a way to long FA but it specifically brings up the introduction of checklists in aviation - specifically. ie a plane crashed and they figured the cause was that it was too complicated to fly so pilots should have checklists to prevent such problems.
Not radical enough (Score:2)
I say this extremely long statement with a bit of experience.
I created an application for exactly this purpose to be used by a major
The numbers are off (Score:2)
Pronovost oversaw the introduction of checklists in the ICUs in hospitals across Michigan, and the result was a thousand lives saved in a year. That would translate to 28,000 per year if scaled nationwide
I know that the US medical system is in tatters but surely you have more than 28 large hospitals nationwide???
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Never mind I just saw my error. He didn't trial this in one hospital - he did so in a whole state (presumably one that has more hospitals than average since you have more than 28 states).
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The checks in the mail. (Score:3, Funny)
"The article goes on to profile a doctor named Peter Pronovost, who has extensively studied the ability of the simplest of complexity tamers â" the checklist â" to save lives in the ICU setting."
1) Is patient alive? No check.
2) Search wallet. Check.
1% is actually quite awful (Score:4, Insightful)
Imagine if the brakes on your car failed just 1% of the time. For every 100 times you brake 1 time you'd just keep going. How many times do you brake on an average 1 hour trip? Sometimes for mission critical systems even 99.999% isn't good enough. It's not just mission critical systems though. What about computers. If they made errors once in 10000, with several billion cycles per second, they'd be unusable.
Anyway if each patient requires 178 actions then 1% means every patient has between 1 and 2 mistakes made for them per day. I presume some of these actions are trivial otherwise I'd be amazed if anyone survived.
Re:1% is actually quite awful (Score:4, Insightful)
You are comparing apples to... well not even oranges... to manhole covers. With a computer or a mechanical device it is possible to ensure that failures don't happen 99.999% of the time. With human beings taking actions that is much less reasonable.
/. That is a reasonable question, but again as soon as there are no more motorcycle accidents, no more drunk drivers, and Vista is taken off the market we can then expect a human being to do any task with 99.9999% perfection.
Though if you think that is possible, go an entire day without making one single mistake. No misplacing your keys. No forgetting the milk at the store. No traffic tickets. No wrong turns while driving. No spelling mistakes while you are typing. No truthfulness when your girlfriend asks you if she looks fat in this dress. Not. One. Single. Mistake.
Of course one might argue that if something important like a life is on the line, people should be much more careful than they are while shopping or typing a reply on
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Though if you think that is possible, go an entire day without making one single mistake.
Oh for pity sake. I'm not suggesting we create infalible human beings or require human beings to be infallible. It is possible to ensure people do things much more accurately through a system of redundancy. More than one person checking off on a procedure (when time permits). More checks and balances. Automation of arithmetic for calculating dosages. Automation in diagnostics so that a doctor can check he hasn't missed
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Great. And your health care costs will rise commensurately.
Though I have no idea what you mean with regards to automation in diagnostics? How the heck do you s
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Great. And your health care costs will rise commensurately.
Yes, because industries that have been able to automate have had their prices skyrocket. Like the car industry. Nope. Or the toy industry. Nope. Food manufacture. Um, nope. Mining? Nope.
Though I have no idea what you mean with regards to automation in diagnostics? How the heck do you suggest that this happen given that diagnosis is largely a directed interview with a person augmented by a few elements of the physical exam and sometimes a few lab or
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Counting direct patient care and charting time, but not counting required continuing medical education, teaching, administrative work, and other things related to my job that aren't direct care, I make $80/hour pre-tax. Of course I work 60 hours a week in clinical and charting time so I make a decent wage. Though I have taken exactly one vacation of over 4 days in duration since I
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In addition to the rest of the comments above me, these are 1% errors, not 1% critical errors. It's more like you're walking out the door and you leave your keys behind. Result: you go and get your keys, you car doesn't blow up.
Similar situation here, errors don't have to be big.
We build machines and computers to be able to handle the errors they make in a competent fashion, same thing happens when you forget your keys, you go back and get them.
Error != Failure (Score:2)
Imagine if the brakes on your car failed just 1% of the time.
This isn't a correct comparison. They made errors 1% of the time. An error becomes a failure only when it is allowed to cascade through the system.
We had a similar presentation at work (from one of our grizzled engineers who is also an amateur pilot). A commercial flight encounters, on average, two errors. However, this doesn't mean your average flight crashes and burns; these errors are corrected through redundancy. For example, this is why pilots repeat the instructions given to them by air traffic c
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I have a foolproof plan for implementing this (Score:2)
er, somewhere....
Now, where did I put that thing.
Personal anecdote - it works! (Score:5, Interesting)
Checklists certainly aren't just for medicine, they work great in IT too. As a system integrator / contractor, I've found that lots of IT people have a somewhat.. haphazard approach to day-to-day tasks like building servers or provisioning users. This inevitably leads to mistakes and forgotten steps, which then results in angry users and system failures. Of course, the same IT people then apply the fix with the same lax methodology, and the result is yet another failure, and an even angrier user. I've seen this cycle repeat as often as 3 or 4 times, until managers get involved, and fingers are pointed. It's very unpleasant for everyone after that.
My method is trivially simple, and required nothing other than a text editor, even Notepad works fine, but a more robust editor is even better.
I call it: "Pete's Patented TODO List System". (Patent not pending).
Simply open a new file, and create a line for every single step of the task you're about to do, even if it's blindingly obvious. Prefix each step with a pair of square braces as a placeholder for a check box. E.g.:
=== BUILD SERVER === ...
[o] Back up existing data from drives
[.] Patch BIOS to latest version
[ ] Reset BIOS settings to platform defaults
[ ] Boot installer from \\foo\bar\...
[ ] Configure drives
[ ] Clean existing RAID
[ ] Create mirror pair
[ ] Configure block size to 64KB
Once you have the file, as you build the server, you tick steps off by filling in the checkboxes. E.g.:
[ ] Not done
[.] Started / partially done
[o] Done.
[!] Issue / problem
[?] May not need doing / optional / ask
[-] Cancelled / no need.
So you ask.. why is "Pete's Patented TODO List System" so awesome? Because it works, it's free, and it's flexible. I found my error rate plummeted, and I could then email the list to someone else, and they could reproduce a successful procedure flawlessly by simply following the steps. There's actually a whole range of reasons why a text-based TODO list system is the best for IT:
- It can be cut & pasted back and forth between local and remote systems.
- After a task is complete, you can email it to managers or coworkers as a "record of activity".
- Others can read your list without requiring a client such as Microsoft Project.
- Any idiot can use a text editor without special training. Quickly reorganising the structure and order of a complex multi-step task in dedicated Project management software takes effort, and may cumbersome.
- It's easy to cut & paste parameters, values, scripts and command in and out of the TODO file.
- You can reset a file to "blank" by doing this Regex search and replace: \[.\] => [ ]
- Did I mention it's free? (I do accept PayPal donations, however)
In general, TODO lists rock, especially in environments where scripting everything is not practical. For example, if you build multiple servers in parallel, simply open two Notepad windows, and track the progress of each server. If you're interrupted by a phone call or a user, you WILL forget what exactly you have or haven't done, and that's when fuckups occur.
Not to mention that most IT people just don't do "all the steps", which is one of the main points in the article. For example, do you, or the people working with you, do ALL of the following when configuring a server:
- Wipe all of the existing configuration, including BIOS settings?
- Run a memory check?
- Set the date and time in the BIOS?
- Patch up all components to the correct / latest levels, including obscure things like the network card firmware?
- Install, configure, and TEST the antivirus, backup, and monitoring modules? Did you run a test backup AND a test restore?
- Verify that every step worked?
If the answer is no to ANY of those, you or your people are fucking up on a regular basis, whether you know it or not. I've lost count of the number of times I've seen "enterprise clusters" where 2 of the 5 nodes have a different date & time. It's a trivial thing, yes, but MY GOD DOES IT BREAK THINGS if you forget.
Absolutely!!! (Score:2)
Awesome!!!
I have my entire server provisioning procedure in a single shell script. I run the installer, update everything, and then run my "magic" shell script. When it's done, the system is ready for action.
I think of the shell script as a TODO list, but it's bash that's doing the work instead of me.
I wouldn't have it any other way. Human memory is too fallible, and even written instructions are open to interpretation.
Re: (Score:2)
Awesome!!!
I have my entire server provisioning procedure in a single shell script. I run the installer, update everything, and then run my "magic" shell script. When it's done, the system is ready for action.
I think of the shell script as a TODO list, but it's bash that's doing the work instead of me.
I wouldn't have it any other way. Human memory is too fallible, and even written instructions are open to interpretation.
Yeah, of course, scripts are usually the best method. Computers don't make mistakes, people do.
Not always practical though, and trying to script everything is a nightmare, irrespective of platform. Even if you script or automate, a checklist is still vital, because there's more to it than just "run script". E.g.:
[ ] Redirect users to other cluster node
[ ] Lock server
[ ] Wait for server to clear
[ ] Reboot and run F12 build script
[ ] Check script log file and test server
[ ] Add server to cluster
[ ] Verify use
WTF? This article is a year old. (Score:2)
Umm... I don't know if the editor noticed, but this article was published over a year ago.
How is this news?
Re: (Score:2)
Bigger news! 28,000 more people died!
The actual paper (Score:5, Informative)
It's not as glamorous as discovering a cure for some new disease, but it works great.
Notice the other things mentioned in the New Yorker article:
In fact, the most important part of the whole article is in these paragraph:
This is a year old, but (Score:2, Informative)
But if it isn't being done yet, a reminder won't do any harm!
The most significant thing I find (going from a year-old memory) is that they had to get the bean-counters to increase the amounts of disinfectant and protection sheets they bought, since these amounts increased VERY significantly when check-lists were used!
Collecting and passing information is the problem (Score:2, Informative)
Each time the hand off was done mostly verbal, always asking the same
Checklist has problems though (Score:3, Interesting)
Namely, being that once a check-list is created, after a while, one gets to the point where it's only the check-list that matters. Not on the check-list, doesn't happen. In other words, it allows people to get lazy and not pay attention. So, there will likely be errors produced from that negating the lives saved with nothing gained, but at the same time, a grand potential lose. The lose being a mentality of brainlessness in the ICU.
One must weight also weigh the practical consequences of such things that would have benefits against those benefits as well. We need to see a net gain first. Especially before widespread adoption.
Re: (Score:3, Insightful)
Treatment errors kill (Score:3, Informative)
Not a new idea. (Score:2)
They're called ordersets. I worked for a company that sold subscriptions to them and had software for authoring your own. Subscriptions started at $1 million/year, three year minimum contract. Not out of the question for a large metro hospital, but may be out of reach for the budgets of a smaller county hospital... Last I heard, the company was tanking.
Gathering of success rate data shut it down (Score:3, Interesting)
Apparently they got in a bit of trouble over this - not for instituting the checklists, but for having the gall to track results to see how effective they were. Because of that, it basically becomes an experiment and you have to get all sorts of permissions.
A bit more detail in this NYTimes editorial [nytimes.com]
And some commentary from the University of Houston Law Center: here [uh.edu]
Note that all of this is actually a bit dated - the original New Yorker article was from December, 2007 and the followups that I saw were from January, 2008. I don't know what's happened with it since then; I suspect that checklists have been implemented in some hospitals but that nobody is sharing results.
Comment removed (Score:5, Insightful)
Re: (Score:2)
Anyone who has been stuck eating Ramen for months at a time please raise your hand.
Whaddya mean "stuck", Kimosabe? Ramen noodles are fuckin' delicious! Pop some peas and corn in there and you're ready to rock! :D
Re: (Score:2)
Comment removed (Score:5, Insightful)
Re: (Score:2)
I'm not going to say it's not like that. But it's certainly less true than it used to be, even ten or fifteen years ago.
These days the middle class is getting squeezed seven ways to Sunday. So apart from being good looking, a good [enough] singer or expert at chasing or hitting a ball around, the routes upward are becoming blocked. And all the time the haves - those who were born with money and connections - are entrenching their position e
Re: (Score:2)
Your "socialist paradise" paid for your education by sending the bill to people who actually earn their keep.
Yeah, it came to me after I finished my degree. We basically run our student loans as part of the taxation system. It's called investing in our people.
Re: (Score:3, Funny)
I agree that the earth cannot possibly support more than a few million people, a hundred million absolute tops.
Re: (Score:2)
Lemme guess, you're one of those doctors who refuses to wash his hands*, too, because it's somehow demeaning to a man of your stature to do something so ordinary as scrubbing a little suds.
*it's on the rise, WTF?
Re: (Score:2)
1. then it'll be changed
2. nobody will control all of the checklists in the world; medicine already has processes for developing and disseminating best practices and then on an institution-by-institution basis incorporating those into formal policy. Some such processes
Re: (Score:2)
Er. No. See: CMS. Case in point: blood cultures before antibiotic administration in sepsis. That is an absolute requirement for the Sepsis bundle and yet there is NO evidence that two sets of
Re: (Score:2)
Given the usual standard of doctors' handwriting, I sincerely hope so.
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You're wrong, however.
A life is only worth as much as someone else is willing to pay to preserve it. If no one will pay for your life saving operation, your life wasn't worth the cost of said operation, apparently.
People die every day from lack of money.
Either through starvation, lack of medicine, or lack of surgery.
Its sad, but this is what humanity must do until everyone has food/supplies/shelter given to them for free, and can actually donate their time without having to keep a real job just to keep som
Re: (Score:2)
When well implemented, checklists run very smoothly. If the list itself and the procedure for using it are well understood and familiar, the time cost is minimal and often negative -- you'll never have to stop and think for long about what needs to be done next, because as soon as you start to the person with the list will start reading the next step. More importantly, missed checklist steps result in substantial time losses in the future -- the reduced infection rates mentioned in the article don't just
Re: (Score:2, Interesting)
Let's compare apples to apples. What if you were in a rocket engine testing facility where dozens of rocket engines are simultaneously in danger of failing, and all the rocket engines had to keep running at all costs? Would you want to go through the formality of checklists? If ICU patient #37 died while doctors were going through the checklist for patient #14, won't the media headlines scream that "ICU patients die while doctors are held up by hospital bureacracy"?
There is an interesting recent article
Re: (Score:3, Insightful)
How many of those fire extinguisher deaths are caused by *untrained* operators? I would guess all of them. You don't have untrained operators working in an ICU or at a rocket test site. The more critical the rocket test, and the more chaotic the environment, the more important checklists become. I'm sure the same is true in an ICU. The idea that checklists slow down complex operations is, quite simply, wrong. They usually have a negligible impact on speed, and can often speed things up. Frequently th
Re: (Score:2)
Imagine that most of the time, the "failure" isn't catastrophic (ie, patient death), but rather a failure of the test itself, merely requiring the engine to spend more time (ie, prolonged ICU stay) in retesting. The reduction in failures due to checklists will obviously cause a reduction in total time spent testing, causing a *reduction* in workload.
The question of which checklists are useful could then be reduced to a very simple economics problem, involving initial failure rate, time spent per checklist,
Re: (Score:2)
This is possible. Certainly, for you individually, it's always going to be safer to walk away from a small localized fire instead of trying to extinguish it.
If the fire is in a building with other people in it, it can be less clear-cut, it depends on -how- small the fire is, and how quickly you could safely evacuate the building.
But offcourse we care about damage to property too, not only life. I live in a condominium with 6 apartments side-by-side, each apartment is a fire-cell where fire should stay in on
Step two (Score:2)
2) Follow the checklist and eliminate the 1% error that kills 28,000 patients a day.
I know this is /. and you're not expected to read the article. But could you at least read the summary?