My former roommate is a pilot. When I first met him, I noticed that he uses checklists for just about everything, even the most basic everyday tasks.
After some time, I decided to apply that same mentality to my own life. Both in private and work situations.
I get it now. Checklists reduce cognitive load tremendously well, even for basic tasks. As an example: I have a checklist for when I need to travel, it contains stuff like what to pack, asking someone to feed my cat, check windows are closed, dishwasher empty, heating turned down, etc. Before the checklist, I would always be worried I forgot something, now I can relax.
Also, checklists are a great way to improve processes. Basically a way to debug your life. For instance: I once forgot to empty the trash bin before a long trip, I added that to my checklist and haven't had a smelly surprise ever since ;)
Good checklist design is not trivial, however. I use checklists professionally, and the list rapidly accumulates cruft for problems that have been solved by design. E.g., suppose one time someone forgot to sign your software release. "Verify release has been signed" is added to the checklist. However a bright soul also integrates signing into the release build. Thus the problem is essentially solved once and for all, but the item will remain on the checklist in perpetuity, which adds overhead & decreases confidence in the checklist process.
I think they make sense for infrequently exercised routines of moderate complexity that are 100% execution. A complex but limited scope machine like a plane is really an ideal example. I guess preparing for a vacation could be another, although I get caught up because packing is totally different every time. I suppose I checklist myself when I rappel or go skiing ("Skins, skis, boots, ... working up the body")
> but the item will remain on the checklist in perpetuity,
Why do you say this?
Everytime you see a system flaw because of a missed step, you add to checklist. Everytime you have a process flaw because of a uselss step, you remove from the checklist. There's no problem here, checklist maintenance can be a step in the checklist.
> I think they make sense for infrequently exercised routines of moderate complexity that are 100% execution
Yes. There have been several formal studies of this effect, e.g. [0]. Checklists offset skill fade, which is in effect the 'forgetting curve'. Some skills (the classic riding a bike) last for ages, others (a good example being field fault diagnosis) are lost very quickly even with good initial training.
Incidentally, I once made a good camping packing checklist by making an inventory of the contents of my car as I unpacked it at the end of a holiday and the things I'd forgotten were still fresh in my mind.
> I suppose I checklist myself when I rappel or go skiing ("Skins, skis, boots, ... working up the body")
This is a perfect example. I have a snowboarding checklist and it's reduced the cognitive load of packing tremendously.
Things to do the night before, stuff to wear for the drive, stuff to pack, what to include if I'm expecting extra cold weather, and a final checklist for things to do in the morning (e.g. get lunch out of the fridge).
For travel I have a checklist of things that I always need to take (toiletries, spare phone battery, Nalgene, pajamas) and then the stuff that varies is all I have to think about. Almost every time I travel there's something on my list of "stuff that always gets packed" which I would have forgotten.
Another situation in which it helps I think : cooking. At least for me a checklist (written or mental) helps keeping the kitchen clean a makes better meal. For a few years now I've started to plan my cooking like I plan more abstract algorithms.
I trust that someone in the near future will mess with the release build process and the signage will be dropped. Or there might be cases when the signature is suddenly invalid for reasons you cannot forsee yet.
Keep the item on the list, especially if it checks the outcome of a longer process.
I would argue that you want an automated check for "verify release has been signed" then if it fails you are alerted. This is better than manually checking it every time or assuming it will always be signed. A trust but verify approach. Then one day you may find that a trusted cert has expired and signing is broken or a key is not available b/c it got accidentally deleted etc... Lots of things can go and will go wrong.
I confess to not usually using a checklist when I travel because most times are a bit different. What I do though--I travel a lot--is I have a couple containers of "travel stuff" down in my kitchen including some pre-made kits that I just throw in my bag. I pick out what I need, add clothes as needed, and that works pretty well.
I understand you're saying, but this statement exemplifies so well something I think I have gotten worse at since becoming a software engineer.
In my previous life, if I tried to apply checklists to my life, I would have taken a naive approach, applied my best effort, and that would be the end of it.
Now I would be much more likely to consider edge cases and counter-examples, compare my checklists to the "optimal checklist", and as a result I might fall into a checklist-design rabbit hole, or else constantly question the efficacy of my checklists in knowledge of the true complexity of the problem.
I don't think it's always beneficial to think in those terms.
I feel like some people have vastly different sensitivities to doing pointless things. There are some people who would see items like that on the checklist, and go, okay, it's a minute to check that, no big deal, I'll do it and get on with my life. There are people who look at it and are almost offended that their time is being wasted by process. I don't really know what to DO about this, but I do find it's one thing that makes collaborating difficult when a group has members with vastly different tendencies in this regard.
>"Verify release has been signed" is added to the checklist. However a bright soul also integrates signing into the release build.
If that bright soul also added a 'verify the signature' step to the build process, and the ability for the build system to know that signing failed, you've automated the entire thing and now your checklist is documentation for the build process.
Agreed, the book was very well written and the audiobook had a great narrator.
Because of that book, I'm not surprised that the checklist reduced deaths, but its a bit shocking that its by a third. Then again, the base rate was very low to begin with, showing that surgery teams were already doing a seemingly good job:
"The death rate fell to 0.46 per 100 procedures between 2000 and 2014, analysis of 6.8m operations showed."
Still, over 6.8 million operations, is that 15,000 survivals? Wow.
The medical community uses checklists. They've been using checklists for a while. A number of studies found that they only help for a few months, while they're new.
That said, "the medical community" is not a homogeneous monolith, and you can absolutely find regional variation in what checklists are used for, how detailed they are, how closely they're followed, how people are accountable for keeping to them, etc.
"The Checklist Manifesto" chose to overlook the studies about how transient the benefit of checklists is.
Can't tell you how happy it makes me to discover I'm not the only one who does this. My wife says it drives her nuts but I'm pretty certain she's also delighted by how we never forget anything before or during a trip.
We did something similar for example: left a tray of leftover food in the oven (turned off) just before a trip and came back to a pulsating surprise. I added "Check the oven is off and empty" to the list of things to do "Just before we leave" and it's never happened since.
That said, there are several hundred things on my generic version and it sometimes feels a bit daunting having to start afresh each time we travel but I think so far, it's been worth it.
I keep threatening to do a trip without it and see just how many things we forget, don't do and screw up. MAybe one day... :)
I just throw some stuff in a bag and worry less. Never fails. If I forget something it probably was not that important and I can just buy it at the airport / when I land.
I perhaps should have elaborated a bit about the number of items. It is broken up into sections like:
* Do well before we leave: e.g. arrange insurance, book seats on flights.
* Do just before we leave: e.g. engage window locks, turn off heating, empty dishwasher
Then sections for hand carry, electronics bag, wash bag, suitcase and various subdivisions within each.
I found the best way to manage it is to make one giant list so it might have a kite and a bucket and spade in the "misc items" for example. When we're planning a trip, I copy that list to a new place, edit the title accordingly and remove all the items I'm sure we won't need. Like the aforementioned kite and bucket if it's not a beach trip. Or the car pack with chargers, suction cup for phone navigation etc. if we're not renting a car.
I agree that it'd probably be mostly okay if I went rogue and I can always buy stuff in the airport or at our destination. Notable exceptions being medications, passports, credit cards. I still garner some measure of comfort from knowing we have everything even if getting there can be a little stressful.
> I keep threatening to do a trip without it and see just how many things we forget, don't do and screw up. MAybe one day... :)
I don't have a checklist, and usually I'm fine. So, it's certainly possible :)
Also, I think if you have a list of over 100 items, maybe it's time to simplify it or break it up into sublists. That length itself probably produces more anxiety than saved by the list. It sounds like an over optimization
For background, I create todolists and checklists all the time in my life. Just so far, I haven't felt the need to make one for taking vacations.
I don't know how I'd live without checklists and Trello boards. Just running a family with a couple of kids, I don't get how people used to do this.
Each kid has their own schedule, their own list of items they need that day, their own homework.
When you shop, you need to know what to get for everyone.
And there's the paperwork, you have to decide what to buy for major purchases and pay for them all, and you have to sign up to various things like voting registries and local tax.
Add to that your work, where you have a bunch of tasks to do as well, various projects, bugs, meetings, and so on.
I lived through the pre-mobile, pre-everyone-had-a-computer era, and I don't get how people did anything. Paper diaries? Rolodexes?
The best way to organize things is to not have so many things to organize.
People certainly are busier now, but they seem to be a lot less focused on important things.
Kids playing used to be spontaneously organized by the kids, or even organized in advance by the kids. The amount of available greenspace in a neighborhood seems to be a lot less now, and play appears to be monetized and organized by adults and organizations.
Read Samuel Pepys diaries from the 17th century. They're available online in various forms. It's fascinating both what has changed and what hasn't changed at all. Pepys wrote these diaries primarily for his own use and so he sends to be largely honest (at least as much as we are honest with ourselves). He describes cheating on his wife, lying to people and so on.
Anyway, Pepys complains frequently that his day's work was lost because he was not able to meet with someone in the expected place at the anticipated time. That's just how things were then, you could neither phone to ask "where are you?" nor to say "change of plan I will now be at the old bridge until 4pm".
My own anti-anxiety strategy for thinking like making sure the cooker is off, windows are closed etc. is to take pictures with my phone of everything (of course I never look at the pics).
I suspect there might be an opportunity for a "visual checklist" app that prompts you to take pictures of stuff....
NB I do use a paper checklist for remembering to take stuff when I go up mountains at the weekend - forgetting gloves when it is snowing is never a good idea.....
"Originally developed by the now-defunct Kobe Railroad Administration Bureau in the late Meiji Period (the early 20th century), pointing-and-calling is known to reduce workplace errors by up to 85 percent, according to one 1996 study."
I've used a packing list for travel for a while now. My current method is to set everything up with checkboxes, uncheck them all beforehand and then recheck them as I pack or as I decide I don't need them for this trip.
I used to just group items by category (outerwear, electronics, etc), but now I've found it better to group items by where they're going to be packed (pockets, under-seat backpack vs carryon / checked bag).
Below that, I have short supplemental lists for things like camping, international, trips with swimming/beach, formal (wedding, etc), or trips longer than a week.
Also, a "Before You Go" list that's stuff to remember when literally walking out the door (take out the trash, shut down home theater computer, etc) that isn't realistic to pack or do in advance. Still a work in progress, but it really helps free up mental energy.
I do almost the same, but the “Before You Go” list is a great addition. I’ve got a couple of different checklists in Trello for different kind of trips: week of snowboarding, long weekend with my wife, business trip to conference, camping with family.
As a pilot, we use checklists in a solo flight differently than in a crew flight. I fly solo flights by “flows,” and then use/review the checklist at the completion of a flow to confirm I did not miss any step. In general the flows are a right-to-left arrangement of things you do in a certain phase of flight. That way you scan over the things in order and do/verify everything in a single “flowing” motion.
I have checklists for almost everything. Recently I’ve started worrying that I’m depending too much on them because I should be able to think up things I need to do without these checklists. As in I’m not engaging my brain as much. But your comment just made me realize that now I have the cognitive load to do things other than remembering tasks. I recently passed two licensing exams without being stressed out that a lot of my friends failed. And I think I may attribute my checklists habit to that.
(Shameless plug from a happy user: I rely heavily on the Things app for Mac and iOS)
I credit checklists for being much more creative in my work and personal life. An in-memory checklist is a huge distraction. Once you flush it to offline storage, you have more memory for other things, like thinking about how to solve the harder problems in life.
I spend a lot of time getting checklists together at work, mostly for other people, and then ruthlessly removing extraneous items from the list (usually by fixing unreliable things that are of the sort: step 5: Do X. step 6: double check that step 5 actually happened)
I get lots of credit for the former, but maybe one in five people see the latter as the bigger contribution.
We end up having to deal with things when we are tired. You have to make them so an idiot can do them, because some day you will be that idiot. All day exhausting meeting followed by a major emergency. Kid up half the night with a fever. New video game just came out. Bad dreams, whatever.
With regard to the difference between pilots and surgeons in this matter, it has been noted that the latter are not personally at risk from not using checklists. I am not suggesting that surgeons deliberately or cavalierly put patients at risk, but risk to oneself has a way of concentrating the mind.
There's an anecdote in The Checklist Manifesto which backs this up. I'm recalling from memory, so the details may be off, but when they tried to roll out a checklist program into a hospital, many of the surgeons resisted, feeling that it was insulting. After having used the checklist process for a while, this sentiment remained, but when surveyed "If you were going under the knife, would you want a surgeon who uses the checklist process", nearly all of the surgeons answered "yes". (when their own life is on the line, suddenly a checklist doesn't seem to repugnant)
Yep. What surprised me: certain things end up with surprisingly long checklists. My "monthly" checklist at home has 30+ items on it, and it's not padded.
When I hit 50 I started making lists like a mofo, because I realized it would relieve my cognitive load. And it did, big time.
I do this. Everyone seems to think I'm insane however. This is the same people who's lives regularly descend into chaos doing the same stupid things over and over again.
I would likely forget something if I didn't have a travel checklist. Something I keep in my Evernote notebook called, wait for it, checklists :-)
They are especially handy when on multi-stop travel where I'm spending all my time worrying about the logistics of the travel and meetings. It has definitely saved me from losing a number of phone chargers and razors over the years.
I see the appeal and do it to some extent. However I haven't finalized on a system for it.
I've realized that there is quite a bit of overlap between some of my lists and have been thinking that I'd like it to be a modular system. A checklist consists of a any number of items and sublists so that one can quickly combine them.
For instance, travel might optionally include the sublist abroad and/or skiing or summer. A work-related trip might add another set of items etc.
I bet there are apps for this and I think I found a few when looking, but I'm afraid of the managing overhead and would like access to it on my phone and computers without cloud bloat. Maybe git + vim-wiki or something is good enough (would also work well enough on an android phone with termux).
I've found that using checklists helps tremendously when working on medium to large projects (things that take more than a weekend to complete).
For example, if I want to learn a new technology, maybe I'll get a book on python, add the list of chapters in my projects tracking document, and strike them off one by one.
Checkslists force me to really have some kind of plan for achieving a certain goal - how I want to achieve something. Because I have to be able to write down the single steps.
Also checklists make it very easy to just get started.. just begin with the first task
And last but not least - I use checklists especially for things that I do NOT want to do at all (but I will have to do anyway). I am already annoyed (for whatever reason) by that task - so I want to minimize the amount of time I have to spend dealing with it. Therefore I use a checklist with the minimal amount of necessary steps to solve that problem or task, so I can get rid of it as fast as possible.
Maintaining checklists in documentation for software design reduces mistakes dramatically. Writing step-by-step exacting build instructions for one of our core products reduced the annoying requests for help I got dramatically.
In my twenties, I kept medical appointments in my head for me and both kids a year out. I never saw any point in jumping through hoops to put it in a calendar. It struck me as a pointless time waster to write things down that I was going to remember without writing it down -- and then have to also keep track of the calendar, check the calendar regularly, etc.
My messy stacks of papers made me look disorganized, but I could find anything important within ten minutes. In contrast, we routinely tore the house apart for an hour looking for something of my husband's.
He liked to organize and file and alphabetize. But the things he failed to organize often ended up in a heap on the floor. He did all that because he couldn't keep track of it mentally.
If your life works without checklists, don't worry about it. But if you find you start overlooking important details as you get older/busier/in a new and unfamiliar situation, you might revisit the idea.
Just don't rain on someone else's parade. Check lists work well for many situations and are especially valuable when lives are on the line for some reason (or similarly critical situations where mistakes often happen for various reasons).
I have an extensive checklist for trips. I’ve also got a daily one, which is partially for helping me get the day started off right by checking off a bunch of easy tasks, and partially just to make sure I don’t miss something critical. Ever forget about a meeting you needed to prepare for until you got the meeting reminder? I have a daily checklist item to give my calendar a quick glance to make sure there’s nothing I need to prepare for. It only catches something maybe a few times a year, but that’s worth it for the 10 seconds it takes me every day.
Pretty much anything I have to do more than once, that involves more than a few steps, I make a checklist for. I take pictures sometimes, semi-professionally. I have a checklist for what to do before I take pictures (pack the bag, charge the batteries, clear the memory cards), and after (brighten teeth in pictures, remove lint/spots from clothes, pick photos to put in my portfolio). At work I have checklists for design tasks, some of which are things to do, some of which are things to consider (does this need a review from security? does this need additional monitoring?).
There are people that can keep all this stuff in their head. I’m not one of them and I know it. Having checklists reduces my anxiety levels by an order of magnitude.
In development, could be "pre-release/pre-push-to-production checks".
I've used them for video shoots too (e.g. pre-interview: "is camera charged? is extra battery on? are audio levels good? is frame ok? ND filter needed? took 10 second ambience audio sample? took b-roll?" etc.
We use checklists (to varying degrees of efficacy and adherence) at work. Obvious case: test procedures (for larger test cases and suites, not unit tests and automated tests). We also use them for things like peer reviews or releasing products to customers (to ensure we've asked the right questions, are releasing the correct product, have done all the things necessary to release the product, etc.).
Given that any routine could be made into a checklist, it seems likely that you have lots of everyday checklists that you do a good (or good enough?) job of keeping track of in your head.
Maybe for most things that you could use a checklist for, the effort just isn't worth it?
If I remember anything from the "Getting Things Done" training is precisely this:
Writing down tasks saves you a lot of brain cycles and also removes worries, as otherwise you have to be constantly "refreshing cache" on pending tasks to not forget about them.
I use the Things app. It allows you to have Projects Area with project inside (collapsible). The checklists inside can have sub-checklists. The sub-checklists can be marked “done” with a check mark or marked “not needed” with a cross.
projects have headings so you can organize different tasks in that project.
Things only stores checklists. Doesn’t share them.
I get the point of checklist for critical process. But I think it's counterproductive to drone your life away following task lists full of feature creep.
First with a little training you can put mental reminders in your mind, trusting yourself that they will show up when needed. It also helps with keeping your brain and memory in good working condition, and force you to stay in mental clarity and not being so overworked and tired that you have to rely on external list.
Second it's not robust to rely 100% on a task list being completed, sometimes forgetting something means that it's not that important. It's more important to rely on situational awareness to know what's need to be done and in what priority. The logic behind is pick something from the hot mess and make the whole better.
Third we can automate and delegate more easily now, quite often if you need to use a checklist, a script would be even better.
Think the "Checklist Manifesto" addresses your creep and clutter as basically a very bad design. In the book they went over several medical checklist iterations before they struck something sensible that improved conditions and saved lives. Most importantly, they changed culture in places to where a nurse was allowed to tell a doctor "no" without fear of reprisals, and re-framed checklist items to pay attention to a time window for administering antibiotics, not just whether a patient received them. The checklist that's helpful should fit on a laminated index card and it should list critical things. But, it's hard to distill the essence of something and most checklists end up as a loose thought vomit on pages.
I work on software related to medical drilling. Nurses run through simulations (mostly a situation where something has gone wrong) and get graded.
It baffled me to learn that this is NOT the norm at hospitals. Due to the stress of a situation-gone-awry and inexperience, some horrific things can happen.[0][1] In some situations you may only have a few minutes to enact corrective procedures. In any case without checklists (and without experience from running routine simulations) it's very easy to make mistakes or forget what to do.
I thought the checklists themselves were standard but it appears not...? The more I learn about hospitals' operating practice the more wary I become. I have no idea why hospitals aren't like the aviation industry and have checklists and expiring certifications. (Or maybe I heard wrong and I'm just completely wrong here.)
> Mead said the principal risk is a patient’s airway. He explained that a child’s breathing tube can collapse without warning under sedation.
> “It happens instantaneously,” he said. “You have maybe half a minute to make critical decisions about how you're going to manage that child's airway. You can't do that if you don't have somebody competent there helping you.”
I was part of a start-up developing checklist for high risk pregnancies. The checklists were developed by some of the best doctors in the country, who had already proved the worth of using checklists in their own practice. Even with all of that, we had unending push back from every single hospital we talked to. Eventually it killed the company because deals could not be closed. I still hear of hospitals saying they want checklists, and they keep saying that until they see one, and then they don't want it anymore.
Also, it wasn't a cost issue. The package was pretty cheap all told. The push back was in the "system getting in the way"...which was kind of the point unfortunately.
Atul Gawande talks about the importance of developing checklists collaboratively with the people who will use them as opposed to imposing them top down.
Many procedures in hospitals are checklist-driven. Peter Pronovost had an early, high-impact publication on the topic of bloodstream infection prevention with checklists: https://www.nejm.org/doi/full/10.1056/NEJMoa061115
I was surprised too, I worked on software for Surgery checklists a decade ago and thought it was standard practice and that only our digitization of it was new, the effects of a checklist have been known for quite a while now. The software I worked on would track every instrument and screw taken into a theatre (using hand scanners), the doctor would have his list of steps for the procedure and the equipment necessary, standard emergency packages were available for the exceptions, etc. It's not just for the direct patients either, some disease can survive instrument sterilization so knowing who else they've been used on can be important.
In the aviation industry, lawsuits aren't necessary. If a pilot makes a serious enough mistake, he dies. If we executed doctors when their patients died, lawsuits would be the least of their concerns.
If anything that sounds like a great reason for a doctor to use an industry standard checklist. "See exhibit A, documenting that my client followed the proper procedures". Not that that necessarily sounds great for patients with legitimate suits but for doctors it sounds useful.
The solution may be found in the legal system and its corresponding arm, the malpractice insurers, if both were to mandate a minimal standard of care including the use of checklists.
One of the issues I've seen in implementing checklists is actually the urge of people to put extreme detail into the checklist and people not putting items in a reasonable order. If you look at the referenced checklist (https://apps.who.int/iris/bitstream/handle/10665/44186/97892...) it is a very approachable list that acknowledges good skill in the people involved. Note that the "before patient leaves" checklist mentions the sponge count but the pre-incision checklist does not. That's because a sponge count is simply part of the job of an instrument nurse and something they always do when they open a pack of sponges.
It's also hard to insert checklists into established procedures. One thing you could do is attach them to important parts that are not allowed to be used until you read the checklist. For example, you could refuse to unwrap the main surgical pack until the pre-incision checklist is followed. Pharmacy could wrap the anesthetic induction drug in the first checklist. The surgeon could be responsible for signing the final checklist in order to get paid.
Keep checklists simple, use them every time. Put them in places where they have to be used.
Wise cautionary note. Use the right tool for the job.
Back when we used to burn "golden" CD-ROMs for releases: Our checklists were getting too unwieldy, we were still making mistakes.
So I started a Go/NoGo process, aka Roman Evaluation. Any one could stop the release for any reason. We'd fix the problem(s) identified, try again the next day.
(Of course, we fed each release's results back into process during the post mortems.)
These seem like very common-sense things to check - Is this the right patient? Are the instruments sterile? Have we counted all the surgical equipment after the procedure?
Maybe so. When was the last time you forgot to do something that was "common-sense"? Forgot to pick up your coat after work? Left your wallet on your desk? Now imagine each of those mistakes was fatal for a patient.
Maybe a shift-change caused the surgical team to be different from normal, so people aren't as comfortable with each other. There's social/professional pressure to fit within a hierarchy, especially with new people. Maybe a few people lower on the totem pole think something might be off, but don't want to say anything lest they risk appearing to undermine the surgeon.
So, at first it appears that a whole room of people would need to independently make the same mistake. But that's not so; only a few critical people need to make the mistake, and with enough ambiguity in the process (easily caused by anything happening 'out of the ordinary'), it won't be corrected some percentage of the time. Even seemingly trivial things.
The FAA found this occurring in the cockpit, especially from the '3rd seat'. A pilot and first officer may be 'in the weeds' dealing with the immediate threat of a situation, whereas others have the benefit of distance to reflect on a situation and observe more clearly. They don't get tunnel vision, and are in a better place to diagnose a tricky problem. However, they may not feel empowered to speak up, or feel they don't have the information the pilots do. Aviation has, broadly, sought to correct this and encourage anyone to speak up. Recently, this happened during the flight before the Indonesia 737 crash where similar AoA/MCAS issues occurred, but a 3rd pilot helped to address the situation.
It's always worth remembering that "after" can be after 10+ hours of continuous high-stress concentration, so remembering lots of little things can be very challenging.
I'd bet more often it's two people who could each do the other's role and therefore wanting to be specific that one person is responsible for X and the other Y.
That's the sign of a good checklist. The idea is to free up mental processing to focus on harder issues. Let the doctor focus on the hard stuff and not spend excess time trying to remember the simple stuff.
.... They haven't been using checklists? I've been getting so upset at the medical community recently. Pilots solved most of these problems decades ago. We've been trying to help them figure out these tools that we developed to save lives, but it seems like things are only changing one funeral at a time.
"500yr of progress being held back by 500yr of tradition" is highly applicable to the medical profession. There's a lot of arrogance floating around the medical profession as well that tends to put a damper on anything that might reduce human error.
Surgeons don't need checklists because they don't make mistakes, unlike those filthy three dimensional bus and truck drivers. /s
> "500yr of progress being held back by 500yr of tradition" is highly applicable to the medical profession.
Is that true of most professions? The difference being we only really care when lives or large quantities of money are at stake. Probably more the later and less the former unfortunately.
>Pilots solved most of these problems decades ago.
In the safest planes (commercial airliners), pilots have systems recording their control inputs, and these can be used to directly attribute damage to/loss of the airframe to pilot malfeasance; the shame of a clear screwup will be clearly documented and in most cases, divulged to the public.
Medical professionals, on the other hand, seem to face a lower standard of accountability simply because it's truly far more difficult (if not impossible in some cases) to monitor all the variables associated with treating a patient compared to monitoring human-designed systems. I have to wonder if this epistemic quagmire where cause and effect are not necessarily tracked (and in some cases, not even truly understood) leads to a mindset that is more willing to write off negative outcomes as the result of external factors (comorbidity, patient age, patient adherence to physician instructions, even pure luck/probability) than tackle the tough problem of correlating personal behaviors and actions to distinct outcomes.
It's not hard to record all patient-doctor interactions. But it is almost certainly illegal in most jurisdictions, supposedly for patient privacy reasons.
That this also helps making doctor mistreatment claims hard to prove is hopefully an unintentional side effect. But you have to wonder...
Unfortunately, there's a lot of resistance to using checklists, from the nurses to doctors. I wish they'd just swallow their pride and worry more about how to improve than how it makes them look when their mistakes become visible and explicit to the people around them.
This is something of a case of "Physician - heal thyself".
I've advocated the use of checklists in software for decades. I wrote something 5 years ago and posted it here[0][1]. The discussion was enlightening. Read the discussions, keeping in mind the comments here about the resistance encountered by people in the field.
Many of the points in the discussions are useful and can be used to create and adapt checklists, but no, they are being used to dismiss them out of hand.
I wonder how much of this is due to the self-selection of the profession in terms of personalities. Surgery in particular is known to attract Type-A personalities. I witnessed similar attitudes in healthcare and other high-status positions where hubris makes them think they know better...until they have an accident. And even then, there's a strong urge to rationalize the outcome as unavoidable
They have been using checklists. This news is that they've measured how much harm has been prevented. It's the first country (Scotland) level research.
> The findings, reported in the April 17 British Journal of Surgery, are based on an analysis of 6.8 million operations performed between 2000 and 20014. The Surgical Safety Checklist was introduced in Scotland in 2008 as part of the Scottish Patient Safety Programme, and by 2014 the rate had decreased by 36.6 percent over six years to 0.46 deaths per 100 procedures. Researchers noted that this fall in death rates was not seen in patients who did not have surgery.
The medical community uses checklists. They've been using checklists for a while. A number of studies found that they only help for a few months, while they're new.
That said, "the medical community" is not a homogeneous monolith, and you can absolutely find regional variation in what checklists are used for, how detailed they are, how closely they're followed, how people are accountable for keeping to them, etc.
>I've been getting so upset at the medical community recently
Don't confuse media narratives with what's actually going on in the medical community. It's a sure-fire way to get (a) upset, and (b) entirely misled. Medical science has been a major target for media FUD for ages.
I have been in hospitals and seen them going through checklists with my own eyes. I don't think your assumption is completely accurate. Maybe it depends on the health system, the procedure, or the facility.
The potential benefit of having checklists is enormous, and people's lives are on the line.
Many people rightfully ask
> Why has this not been adopted everywhere _yesterday_?
A book I read a few years ago might have the answer.
_Catastrophic Care: How American Health Care Killed My Father—and How We Can Fix It _ [0]
Here's the description, to evaluate if you want to give it a read:
> In 2007, David Goldhill's father died from a series of infections acquired in a well-regarded New York hospital. The bill was for several hundred thousand dollars--and Medicare paid it.
> These circumstances left Goldhill angry and determined to understand how it was possible that world-class technology and well-trained personnel could result in such simple, inexcusable carelessness--and how a business that failed so miserably could be rewarded with full payment.
> Catastrophic Care is the eye-opening result.
> Goldhill explicates a health-care system that now costs nearly $2.5 trillion annually, bars many from treatment, provides inconsistent quality of care, offers negligible customer service, and in which an estimated 200,000 Americans die each year from errors. Above all, he exposes the fundamental fallacy of our entire system--that Medicare and insurance coverage make care cheaper and improve our health--and suggests a comprehensive new approach that could produce better results at more acceptable costs immediately by giving us, the patients, a real role in the process.
If we had a medicare-for-all system, we could provide some economic discipline by having high deductible plans, even if those plans are completely covered by a government-funded HSA plan of equal value. As long as the HSA could be withdrawn for retirement if unspent.
We also need transparent pricing and reviews. Sites like ZocDoc are trying to fill the niche of something like Yelp but for doctors. There's lots of easy low hanging fruit here.
Atul Gawande explains in great detail how simple checklists can have big impacts.
For example, why would you need everyone in the room to say their name and what they do?
Simple: everyone is wearing a mask and often surgical scrubs that are the same color. By having everyone say "Hello, my name is Dr. Jones and I'm the anaesthesiologist" you can quickly determine who is the person to direct questions to about the patient being under.
It gets even crazier when you hear stories about doctors going into the wrong operating room (especially at bigger hospitals where there are several ORs). A simple "State who you are and why you are here?" costs very little and helps avoid costly mistakes.
Another example: having a checklist allows a junior person (e.g. a nurse) to challenge more senior people when they make a mistake.
Example without checklist:
Nurse: Dr, I think you forgot to do X.
Dr: I know what I'm doing, don't question me.
Example WITH checklist:
Nurse: Dr, you missed step #4.
Dr: I'm sorry, you are correct. We all agreed that was a necessary step and I missed it.
As have others in sibling threads, highly recommend Gawande's Checklist Manifesto.
Your example depends more on the personality (and mood) of the surgeon than on the existence of a checklist.
Example without checklist:
Nurse: Dr, I think you forgot to do X.
Dr: Oh, you are right, thanks a lot
Example with checklist :
Nurse: Dr, you missed step #4.
Dr: I have done this list every day for the past 15 years, I know I ddid not forget anything, don't question me
The solution to that is to have people have proper uniforms. Eg surgeons/doctors/nurses wear different color scrubs & hats or insignia for rank. It was like this in the old days.
A lot of airline-style cockpit resource management is being adapted for operating theatres, and it is a good thing.
If a junior person thinks that a senior person is about to make a terrible mistake, then the word "Stop!" should be used, along with the reason. That word will often make even the most arrogant person pause and think about what they are doing.
Humans can hold about 5-7 things in working memory. You'll note there are 22 items on that list + the headings of when to do them.
Expertise and practice makes some of those things automatic, but not enough to reduce it all below 5-7. Further, in any surgery there will be other things going on that require cognitive attention, decreasing capacity for other things.
Everything you can do to reduce cognitive overhead makes a process smoother.
I teach the LSAT. One section logic games (officially, analytical reasoning) tests precisely this cognitive load. Students must work with 4-6 rules + what the situation calls for on question.
The rules are impossibly simple. But, in the heat of things, students just aren't capable of working with that many items unless they create a structure using diagrams. And even seemingly tiny efficiencies have an outside effect on speed and correctness.
Don't forget that these surgeons are often tired busy and stressed, three factors that worsen performance. Having a clear list that says "do this now dummy!" massively helps keep you on track even when you're a wreck.
A lot of the time, people ignore over small, simple things because they either assume someone else already took care of it or that it's such an obvious thing that how could anyone not notice. The checklist forces you to actually look up and see that the extra blood needed for the surgery didn't show up or that one of the surgeons present is actually supposed to be in another OR.
It's like help desk asking you if it's plugged in. You may think of yourself as a technical person and that the problem is more complex like the driver isn't loaded or the monitor isn't properly configured but the problem could just be that you forgot to plug the video cable in. Just having those basic checks occur before anything can go wrong makes it so that when things do go wrong, time doesn't need to be wasted on going over the simple stuff or even worse, forgetting about the simple stuff and going down the wrong route.
In any profession most practitioners are bad at what they do. There's nothing magical about medicine that exempts that profession from this rule. If your mechanic can forget to refill the oil in your engine there's no reason to believe that your surgeon won't leave a knife in your abdomen. There will be by necessity bottom-tier doctors and the checklist helps bottom-tier doctors stop killing people.
Not just bottom tier... humans are very good at making simple mistakes. It's one of the things we do best. A lot of times the people who are rated as "good" or "great" are rated that way because the make fewer mistakes, not because of perfection.
I'm not. A clinician is a human, and as a human, they can be distracted, tired, hungry, or any number of things that can reduce their cognition leading them to miss something. A checklist reduces cognitive overhead and provides accountability (no way a clinician would remember if they did or didn't do a particular action days or weeks or months after the fact).
>I'm a bit perplexed that something so simple, can reduce post surgical deaths by a third.
Because it didn't. It attributes the entirety of a decade long decline to the check list, which is obviously nonsense. I'm not saying that checklists aren't good, but they're not miracle workers.
Please point out the parts of it that you find to be scientifically failing.
There's a valid point to be made that the original article implies a greater causal link than the study, but that isn't the study's fault, and it doesn't actually diminish the effect of the checklist in the process. Poor reporting on science is always a problem, and journalists typically use layperson phrasing in order to make the information more consumable.
"The Checklist Manifesto" by Dr Atul Gawande details how resistant to change Medical Professionals can be to procedure. I thought it was hyperbole until I sat in on a certification training for a hospital group and the toxic cloud of chatter about not changing anything because it didn't make a difference was jaw-dropping.
Readit News
After some time, I decided to apply that same mentality to my own life. Both in private and work situations.
I get it now. Checklists reduce cognitive load tremendously well, even for basic tasks. As an example: I have a checklist for when I need to travel, it contains stuff like what to pack, asking someone to feed my cat, check windows are closed, dishwasher empty, heating turned down, etc. Before the checklist, I would always be worried I forgot something, now I can relax.
Also, checklists are a great way to improve processes. Basically a way to debug your life. For instance: I once forgot to empty the trash bin before a long trip, I added that to my checklist and haven't had a smelly surprise ever since ;)
I think they make sense for infrequently exercised routines of moderate complexity that are 100% execution. A complex but limited scope machine like a plane is really an ideal example. I guess preparing for a vacation could be another, although I get caught up because packing is totally different every time. I suppose I checklist myself when I rappel or go skiing ("Skins, skis, boots, ... working up the body")
Why do you say this?
Everytime you see a system flaw because of a missed step, you add to checklist. Everytime you have a process flaw because of a uselss step, you remove from the checklist. There's no problem here, checklist maintenance can be a step in the checklist.
> ("Skins, skis, boots, .
"Spectacles, testicles, wallet, and watch!"
Yes. There have been several formal studies of this effect, e.g. [0]. Checklists offset skill fade, which is in effect the 'forgetting curve'. Some skills (the classic riding a bike) last for ages, others (a good example being field fault diagnosis) are lost very quickly even with good initial training.
Incidentally, I once made a good camping packing checklist by making an inventory of the contents of my car as I unpacked it at the end of a holiday and the things I'd forgotten were still fresh in my mind.
[0] https://www.gmc-uk.org/-/media/about/skills-fade-literature-...
This is a perfect example. I have a snowboarding checklist and it's reduced the cognitive load of packing tremendously.
Things to do the night before, stuff to wear for the drive, stuff to pack, what to include if I'm expecting extra cold weather, and a final checklist for things to do in the morning (e.g. get lunch out of the fridge).
For travel I have a checklist of things that I always need to take (toiletries, spare phone battery, Nalgene, pajamas) and then the stuff that varies is all I have to think about. Almost every time I travel there's something on my list of "stuff that always gets packed" which I would have forgotten.
Or maybe a checklist for refactoring all the checklists?
/this could get out of hand...
I understand you're saying, but this statement exemplifies so well something I think I have gotten worse at since becoming a software engineer.
In my previous life, if I tried to apply checklists to my life, I would have taken a naive approach, applied my best effort, and that would be the end of it.
Now I would be much more likely to consider edge cases and counter-examples, compare my checklists to the "optimal checklist", and as a result I might fall into a checklist-design rabbit hole, or else constantly question the efficacy of my checklists in knowledge of the true complexity of the problem.
I don't think it's always beneficial to think in those terms.
If that bright soul also added a 'verify the signature' step to the build process, and the ability for the build system to know that signing failed, you've automated the entire thing and now your checklist is documentation for the build process.
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https://www.amazon.com/Checklist-Manifesto-How-Things-Right/...
Because of that book, I'm not surprised that the checklist reduced deaths, but its a bit shocking that its by a third. Then again, the base rate was very low to begin with, showing that surgery teams were already doing a seemingly good job:
"The death rate fell to 0.46 per 100 procedures between 2000 and 2014, analysis of 6.8m operations showed."
Still, over 6.8 million operations, is that 15,000 survivals? Wow.
Same author as the book, but earlier. Contains all the meat, but none of the repetitions and the tenuous analogies.
Gawande had enough for a long-form article, but not for a book, and IMO it shows.
The book isn't bad. It's just that the essay is better.
That said, "the medical community" is not a homogeneous monolith, and you can absolutely find regional variation in what checklists are used for, how detailed they are, how closely they're followed, how people are accountable for keeping to them, etc.
"The Checklist Manifesto" chose to overlook the studies about how transient the benefit of checklists is.
You might notice that the book was written by Dr. Gawande, who implemented the checklist in the fine article!
We did something similar for example: left a tray of leftover food in the oven (turned off) just before a trip and came back to a pulsating surprise. I added "Check the oven is off and empty" to the list of things to do "Just before we leave" and it's never happened since.
That said, there are several hundred things on my generic version and it sometimes feels a bit daunting having to start afresh each time we travel but I think so far, it's been worth it.
I keep threatening to do a trip without it and see just how many things we forget, don't do and screw up. MAybe one day... :)
I just throw some stuff in a bag and worry less. Never fails. If I forget something it probably was not that important and I can just buy it at the airport / when I land.
Then sections for hand carry, electronics bag, wash bag, suitcase and various subdivisions within each.
I found the best way to manage it is to make one giant list so it might have a kite and a bucket and spade in the "misc items" for example. When we're planning a trip, I copy that list to a new place, edit the title accordingly and remove all the items I'm sure we won't need. Like the aforementioned kite and bucket if it's not a beach trip. Or the car pack with chargers, suction cup for phone navigation etc. if we're not renting a car.
I agree that it'd probably be mostly okay if I went rogue and I can always buy stuff in the airport or at our destination. Notable exceptions being medications, passports, credit cards. I still garner some measure of comfort from knowing we have everything even if getting there can be a little stressful.
I don't have a checklist, and usually I'm fine. So, it's certainly possible :)
Also, I think if you have a list of over 100 items, maybe it's time to simplify it or break it up into sublists. That length itself probably produces more anxiety than saved by the list. It sounds like an over optimization
For background, I create todolists and checklists all the time in my life. Just so far, I haven't felt the need to make one for taking vacations.
Each kid has their own schedule, their own list of items they need that day, their own homework.
When you shop, you need to know what to get for everyone.
And there's the paperwork, you have to decide what to buy for major purchases and pay for them all, and you have to sign up to various things like voting registries and local tax.
Add to that your work, where you have a bunch of tasks to do as well, various projects, bugs, meetings, and so on.
I lived through the pre-mobile, pre-everyone-had-a-computer era, and I don't get how people did anything. Paper diaries? Rolodexes?
People certainly are busier now, but they seem to be a lot less focused on important things.
Kids playing used to be spontaneously organized by the kids, or even organized in advance by the kids. The amount of available greenspace in a neighborhood seems to be a lot less now, and play appears to be monetized and organized by adults and organizations.
Anyway, Pepys complains frequently that his day's work was lost because he was not able to meet with someone in the expected place at the anticipated time. That's just how things were then, you could neither phone to ask "where are you?" nor to say "change of plan I will now be at the old bridge until 4pm".
Perhaps more time to wonder, explore, and waste.
Perhaps less fulfilling and more difficult to achieve goals.
Carbon based one, ie brain.
I suspect there might be an opportunity for a "visual checklist" app that prompts you to take pictures of stuff....
NB I do use a paper checklist for remembering to take stuff when I go up mountains at the weekend - forgetting gloves when it is snowing is never a good idea.....
The classic example of this are train drivers: https://www.atlasobscura.com/articles/pointing-and-calling-j...
Quote from the article:
"Originally developed by the now-defunct Kobe Railroad Administration Bureau in the late Meiji Period (the early 20th century), pointing-and-calling is known to reduce workplace errors by up to 85 percent, according to one 1996 study."
I used to just group items by category (outerwear, electronics, etc), but now I've found it better to group items by where they're going to be packed (pockets, under-seat backpack vs carryon / checked bag).
Below that, I have short supplemental lists for things like camping, international, trips with swimming/beach, formal (wedding, etc), or trips longer than a week.
Also, a "Before You Go" list that's stuff to remember when literally walking out the door (take out the trash, shut down home theater computer, etc) that isn't realistic to pack or do in advance. Still a work in progress, but it really helps free up mental energy.
I am struggling with how to best organize the items within a section. You have given me some ideas. Thank you.
(Shameless plug from a happy user: I rely heavily on the Things app for Mac and iOS)
I wish I knew this when I was 30.
I get lots of credit for the former, but maybe one in five people see the latter as the bigger contribution.
We end up having to deal with things when we are tired. You have to make them so an idiot can do them, because some day you will be that idiot. All day exhausting meeting followed by a major emergency. Kid up half the night with a fever. New video game just came out. Bad dreams, whatever.
When I hit 50 I started making lists like a mofo, because I realized it would relieve my cognitive load. And it did, big time.
They are especially handy when on multi-stop travel where I'm spending all my time worrying about the logistics of the travel and meetings. It has definitely saved me from losing a number of phone chargers and razors over the years.
I've realized that there is quite a bit of overlap between some of my lists and have been thinking that I'd like it to be a modular system. A checklist consists of a any number of items and sublists so that one can quickly combine them.
For instance, travel might optionally include the sublist abroad and/or skiing or summer. A work-related trip might add another set of items etc.
I bet there are apps for this and I think I found a few when looking, but I'm afraid of the managing overhead and would like access to it on my phone and computers without cloud bloat. Maybe git + vim-wiki or something is good enough (would also work well enough on an android phone with termux).
https://en.wikipedia.org/wiki/Gulf_of_execution
I've found that using checklists helps tremendously when working on medium to large projects (things that take more than a weekend to complete).
For example, if I want to learn a new technology, maybe I'll get a book on python, add the list of chapters in my projects tracking document, and strike them off one by one.
That sense of steady progress helps tremendously.
Also checklists make it very easy to just get started.. just begin with the first task
And last but not least - I use checklists especially for things that I do NOT want to do at all (but I will have to do anyway). I am already annoyed (for whatever reason) by that task - so I want to minimize the amount of time I have to spend dealing with it. Therefore I use a checklist with the minimal amount of necessary steps to solve that problem or task, so I can get rid of it as fast as possible.
My messy stacks of papers made me look disorganized, but I could find anything important within ten minutes. In contrast, we routinely tore the house apart for an hour looking for something of my husband's.
He liked to organize and file and alphabetize. But the things he failed to organize often ended up in a heap on the floor. He did all that because he couldn't keep track of it mentally.
If your life works without checklists, don't worry about it. But if you find you start overlooking important details as you get older/busier/in a new and unfamiliar situation, you might revisit the idea.
Just don't rain on someone else's parade. Check lists work well for many situations and are especially valuable when lives are on the line for some reason (or similarly critical situations where mistakes often happen for various reasons).
Pretty much anything I have to do more than once, that involves more than a few steps, I make a checklist for. I take pictures sometimes, semi-professionally. I have a checklist for what to do before I take pictures (pack the bag, charge the batteries, clear the memory cards), and after (brighten teeth in pictures, remove lint/spots from clothes, pick photos to put in my portfolio). At work I have checklists for design tasks, some of which are things to do, some of which are things to consider (does this need a review from security? does this need additional monitoring?).
There are people that can keep all this stuff in their head. I’m not one of them and I know it. Having checklists reduces my anxiety levels by an order of magnitude.
In development, could be "pre-release/pre-push-to-production checks".
I've used them for video shoots too (e.g. pre-interview: "is camera charged? is extra battery on? are audio levels good? is frame ok? ND filter needed? took 10 second ambience audio sample? took b-roll?" etc.
Maybe for most things that you could use a checklist for, the effort just isn't worth it?
Writing down tasks saves you a lot of brain cycles and also removes worries, as otherwise you have to be constantly "refreshing cache" on pending tasks to not forget about them.
Things only stores checklists. Doesn’t share them.
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First with a little training you can put mental reminders in your mind, trusting yourself that they will show up when needed. It also helps with keeping your brain and memory in good working condition, and force you to stay in mental clarity and not being so overworked and tired that you have to rely on external list.
Second it's not robust to rely 100% on a task list being completed, sometimes forgetting something means that it's not that important. It's more important to rely on situational awareness to know what's need to be done and in what priority. The logic behind is pick something from the hot mess and make the whole better.
Third we can automate and delegate more easily now, quite often if you need to use a checklist, a script would be even better.
It baffled me to learn that this is NOT the norm at hospitals. Due to the stress of a situation-gone-awry and inexperience, some horrific things can happen.[0][1] In some situations you may only have a few minutes to enact corrective procedures. In any case without checklists (and without experience from running routine simulations) it's very easy to make mistakes or forget what to do.
I thought the checklists themselves were standard but it appears not...? The more I learn about hospitals' operating practice the more wary I become. I have no idea why hospitals aren't like the aviation industry and have checklists and expiring certifications. (Or maybe I heard wrong and I'm just completely wrong here.)
[0]: https://www.telegraph.co.uk/news/2018/05/10/premature-baby-d...
[1]: https://www.nbcbayarea.com/news/local/Dental-Anesthesia-Unde...
> Mead said the principal risk is a patient’s airway. He explained that a child’s breathing tube can collapse without warning under sedation.
> “It happens instantaneously,” he said. “You have maybe half a minute to make critical decisions about how you're going to manage that child's airway. You can't do that if you don't have somebody competent there helping you.”
Also, it wasn't a cost issue. The package was pretty cheap all told. The push back was in the "system getting in the way"...which was kind of the point unfortunately.
It's also hard to insert checklists into established procedures. One thing you could do is attach them to important parts that are not allowed to be used until you read the checklist. For example, you could refuse to unwrap the main surgical pack until the pre-incision checklist is followed. Pharmacy could wrap the anesthetic induction drug in the first checklist. The surgeon could be responsible for signing the final checklist in order to get paid.
Keep checklists simple, use them every time. Put them in places where they have to be used.
Back when we used to burn "golden" CD-ROMs for releases: Our checklists were getting too unwieldy, we were still making mistakes.
So I started a Go/NoGo process, aka Roman Evaluation. Any one could stop the release for any reason. We'd fix the problem(s) identified, try again the next day.
(Of course, we fed each release's results back into process during the post mortems.)
These seem like very common-sense things to check - Is this the right patient? Are the instruments sterile? Have we counted all the surgical equipment after the procedure?
[1] https://apps.who.int/iris/bitstream/handle/10665/44186/97892...
Maybe a shift-change caused the surgical team to be different from normal, so people aren't as comfortable with each other. There's social/professional pressure to fit within a hierarchy, especially with new people. Maybe a few people lower on the totem pole think something might be off, but don't want to say anything lest they risk appearing to undermine the surgeon.
So, at first it appears that a whole room of people would need to independently make the same mistake. But that's not so; only a few critical people need to make the mistake, and with enough ambiguity in the process (easily caused by anything happening 'out of the ordinary'), it won't be corrected some percentage of the time. Even seemingly trivial things.
The FAA found this occurring in the cockpit, especially from the '3rd seat'. A pilot and first officer may be 'in the weeds' dealing with the immediate threat of a situation, whereas others have the benefit of distance to reflect on a situation and observe more clearly. They don't get tunnel vision, and are in a better place to diagnose a tricky problem. However, they may not feel empowered to speak up, or feel they don't have the information the pilots do. Aviation has, broadly, sought to correct this and encourage anyone to speak up. Recently, this happened during the flight before the Indonesia 737 crash where similar AoA/MCAS issues occurred, but a 3rd pilot helped to address the situation.
[ ] Yes [ ] Not available [ ] Not applicable
2. If the document refers to a third party report, is it linked?
[ ] Yes [ ] Not available online [ ] Not applicable
3. Are background sources linked to high-quality, external sources?
[ ] At least 3 links present [ ] We sat there for 1 minute and couldn't come up with anything that needs linking
4. Are needless generic internal links to category/tag pages etc. removed?
[ ] Yes
There seems to be a whole other list referenced: "Is the anaesthesia machine and medication check complete?"
Also the team are supposed to intro themselves along with their roles. I wonder if it often happens that someone is missing?
Surgeons don't need checklists because they don't make mistakes, unlike those filthy three dimensional bus and truck drivers. /s
Instead of adapting, they legislate.
And the fantasy that Physicians are unfailing experts leaves you after a you regularly interact with them.
Is that true of most professions? The difference being we only really care when lives or large quantities of money are at stake. Probably more the later and less the former unfortunately.
Dead Comment
In the safest planes (commercial airliners), pilots have systems recording their control inputs, and these can be used to directly attribute damage to/loss of the airframe to pilot malfeasance; the shame of a clear screwup will be clearly documented and in most cases, divulged to the public.
Medical professionals, on the other hand, seem to face a lower standard of accountability simply because it's truly far more difficult (if not impossible in some cases) to monitor all the variables associated with treating a patient compared to monitoring human-designed systems. I have to wonder if this epistemic quagmire where cause and effect are not necessarily tracked (and in some cases, not even truly understood) leads to a mindset that is more willing to write off negative outcomes as the result of external factors (comorbidity, patient age, patient adherence to physician instructions, even pure luck/probability) than tackle the tough problem of correlating personal behaviors and actions to distinct outcomes.
That this also helps making doctor mistreatment claims hard to prove is hopefully an unintentional side effect. But you have to wonder...
I've advocated the use of checklists in software for decades. I wrote something 5 years ago and posted it here[0][1]. The discussion was enlightening. Read the discussions, keeping in mind the comments here about the resistance encountered by people in the field.
Many of the points in the discussions are useful and can be used to create and adapt checklists, but no, they are being used to dismiss them out of hand.
Checklists? We don't need to stinkin' checklists.
I've given up and just use them in my companies.
[0] https://news.ycombinator.com/item?id=7655018
[1] https://news.ycombinator.com/item?id=18522627
> The findings, reported in the April 17 British Journal of Surgery, are based on an analysis of 6.8 million operations performed between 2000 and 20014. The Surgical Safety Checklist was introduced in Scotland in 2008 as part of the Scottish Patient Safety Programme, and by 2014 the rate had decreased by 36.6 percent over six years to 0.46 deaths per 100 procedures. Researchers noted that this fall in death rates was not seen in patients who did not have surgery.
https://www.newyorker.com/magazine/2007/12/10/the-checklist
That said, "the medical community" is not a homogeneous monolith, and you can absolutely find regional variation in what checklists are used for, how detailed they are, how closely they're followed, how people are accountable for keeping to them, etc.
>I've been getting so upset at the medical community recently
http://www.paulgraham.com/submarine.html
Don't confuse media narratives with what's actually going on in the medical community. It's a sure-fire way to get (a) upset, and (b) entirely misled. Medical science has been a major target for media FUD for ages.
Many people rightfully ask
> Why has this not been adopted everywhere _yesterday_?
A book I read a few years ago might have the answer.
_Catastrophic Care: How American Health Care Killed My Father—and How We Can Fix It _ [0]
Here's the description, to evaluate if you want to give it a read:
> In 2007, David Goldhill's father died from a series of infections acquired in a well-regarded New York hospital. The bill was for several hundred thousand dollars--and Medicare paid it.
> These circumstances left Goldhill angry and determined to understand how it was possible that world-class technology and well-trained personnel could result in such simple, inexcusable carelessness--and how a business that failed so miserably could be rewarded with full payment.
> Catastrophic Care is the eye-opening result.
> Goldhill explicates a health-care system that now costs nearly $2.5 trillion annually, bars many from treatment, provides inconsistent quality of care, offers negligible customer service, and in which an estimated 200,000 Americans die each year from errors. Above all, he exposes the fundamental fallacy of our entire system--that Medicare and insurance coverage make care cheaper and improve our health--and suggests a comprehensive new approach that could produce better results at more acceptable costs immediately by giving us, the patients, a real role in the process.
[0] https://www.goodreads.com/book/show/13642523-catastrophic-ca...
edit: formatting
We also need transparent pricing and reviews. Sites like ZocDoc are trying to fill the niche of something like Yelp but for doctors. There's lots of easy low hanging fruit here.
https://apps.who.int/iris/bitstream/handle/10665/44186/97892...
I'm a bit perplexed that something so simple, can reduce post surgical deaths by a third.
For example, why would you need everyone in the room to say their name and what they do?
Simple: everyone is wearing a mask and often surgical scrubs that are the same color. By having everyone say "Hello, my name is Dr. Jones and I'm the anaesthesiologist" you can quickly determine who is the person to direct questions to about the patient being under.
It gets even crazier when you hear stories about doctors going into the wrong operating room (especially at bigger hospitals where there are several ORs). A simple "State who you are and why you are here?" costs very little and helps avoid costly mistakes.
Another example: having a checklist allows a junior person (e.g. a nurse) to challenge more senior people when they make a mistake.
Example without checklist:
Nurse: Dr, I think you forgot to do X.
Dr: I know what I'm doing, don't question me.
Example WITH checklist:
Nurse: Dr, you missed step #4.
Dr: I'm sorry, you are correct. We all agreed that was a necessary step and I missed it.
As have others in sibling threads, highly recommend Gawande's Checklist Manifesto.
Example without checklist: Nurse: Dr, I think you forgot to do X. Dr: Oh, you are right, thanks a lot
Example with checklist : Nurse: Dr, you missed step #4. Dr: I have done this list every day for the past 15 years, I know I ddid not forget anything, don't question me
If a junior person thinks that a senior person is about to make a terrible mistake, then the word "Stop!" should be used, along with the reason. That word will often make even the most arrogant person pause and think about what they are doing.
Expertise and practice makes some of those things automatic, but not enough to reduce it all below 5-7. Further, in any surgery there will be other things going on that require cognitive attention, decreasing capacity for other things.
Everything you can do to reduce cognitive overhead makes a process smoother.
I teach the LSAT. One section logic games (officially, analytical reasoning) tests precisely this cognitive load. Students must work with 4-6 rules + what the situation calls for on question.
The rules are impossibly simple. But, in the heat of things, students just aren't capable of working with that many items unless they create a structure using diagrams. And even seemingly tiny efficiencies have an outside effect on speed and correctness.
Don't forget that these surgeons are often tired busy and stressed, three factors that worsen performance. Having a clear list that says "do this now dummy!" massively helps keep you on track even when you're a wreck.
It's like help desk asking you if it's plugged in. You may think of yourself as a technical person and that the problem is more complex like the driver isn't loaded or the monitor isn't properly configured but the problem could just be that you forgot to plug the video cable in. Just having those basic checks occur before anything can go wrong makes it so that when things do go wrong, time doesn't need to be wasted on going over the simple stuff or even worse, forgetting about the simple stuff and going down the wrong route.
Because it didn't. It attributes the entirety of a decade long decline to the check list, which is obviously nonsense. I'm not saying that checklists aren't good, but they're not miracle workers.
https://onlinelibrary.wiley.com/doi/full/10.1002/bjs.11151
Here's a link to the study.
Please point out the parts of it that you find to be scientifically failing.
There's a valid point to be made that the original article implies a greater causal link than the study, but that isn't the study's fault, and it doesn't actually diminish the effect of the checklist in the process. Poor reporting on science is always a problem, and journalists typically use layperson phrasing in order to make the information more consumable.