The flip side is "sorry, we didn't have enough surgeons available right now so we have to triage you", or, "sorry you can't afford the bill"
I'm sure in this particular situation the numbers benefit "don't leave surgery debris in the patient" but the more general point remains, there is some set of numbers (likely implausible) where it would flip the other way
I know humans are fallable, but I feel like there are some basic, workplace culture driven techniques that could substantially help here.
The main issue is that in most jobs people will say new checklists won't work for /them/ because they understand it better than the checklist, or because the checklist will slow them down. Think about your own work and you'll find reasons why checklists don't make sense, I bet.
I once went in for a surgery on a foot and when rolled into the room the doctor asked me if I had any last minute questions and I asked only 'which foot are you operating on'. After a few seconds of confusion he gave a decisive right answer and even told me 'here, if it makes you feel better I'll sharpie your leg'. And it did make me feel better - there's so much that can easily go wrong by a minor mistake from them which will be life changing for you.
I fought this fight for a long time as an executive in charge of ops with a team that had a critical enterprise product and refused to use source control.
Yes, and The Checklist Manifesto (which is a fantastic book) was published in 2009; yet it seems little progress has been made since.
It's not just checklists, though, it's also basic CRM. If the lead surgeon is God, and you're a nurse, you don't speak up -- you probably don't even believe your own senses when they tell you something's wrong.
A fundamental change is sorely needed -- not sure what will make it happen.
Almost all of the examples discussed are actually checklists: before you do something, you go over the checklist and make sure whatever it says to do has been covered.
But the example of soap distribution in India isn't like that at all. The notional "checklist" was a list of several circumstances in which you should use soap:
1. Before preparing food.
2. After using the bathroom.
3. After wiping an infant.
4. [There were others; I don't remember them.]
This is a good and valuable set of information to publicize. But it isn't a checklist. Interpreted as a checklist, you would need to check it before and after every action you ever take. That is obviously not something people can do. You use this list by doing the work of modifying your relevant habits to include "wash with soap" at an appropriate stage, which is exactly the kind of approach to doing things that the rest of the book is telling you doesn't work.
It's definitely widely used in Germany, where I work. I don't know how common it is in the US, though.
I often think about what makes medicine so different from aviation and your other examples, culture-wise. It's not like there's no safety culture at all in medicine, but clearly these kinds of structures are deployed to a much lower extent.
One major reason might be the far larger diversity of possible situations in medicine. It's possible to make a checklist for surgical safety because every surgery is similar, same to how every plane flight is similar. But if I think about, for example, harm due to adverse effects from medications, or missed abnormal values in blood tests, it feels very difficult to create a checklist to prevent those that would be specific enough to be useful, but also general enough to capture all important situations these might arise in.
In this sense, I think certain “low-hanging fruit” of safety culture improvements have already been captured in medicine. Apart from surgical safety, I can think of check lists for chemotherapy administration, for blood transfusions, for management of a severe allergic reaction, and other specific individual things. Pointing and vocalizing is also done in surgery, albeit in a less formal way. “Two sets of eyes” policies exist in e.g. pathology for more certainty in diagnosis of cancer.
Nevertheless there is clearly room to improve, as evidenced by the continuing occurrence of “never events” such as retained foreign bodies in surgery. There are certainly economic factors at play here as well: unlike in the free market, in the medical system there is often very little economic incentive for quality, and the same principle I mentioned before — of the immense diversity of possible situations — makes top-down regulation very tricky.
Maybe part of it is also that the potential harm from a retained foreign body is much lower than the potential harm from a plane crash. And maybe medical care is so much more common than plane flights that by base rate alone, mistakes in the former will be much more common. Yet I still think there is much that can be done, and I am unsure what exactly is preventing that from happening.
Yes but the major is the number of deaths. An incompetent surgeon can kill at most one person at a time. Besides, variance in surgery is much higher than in aviation.
(I think knots are cool, but I don't really know of motivating examples for why I would hypothetically need them.)
Of course it’s not every surgeon, but there are some butchers that out happens more with. It ended up being a repeat problem for my mother’s surgeon.
Yes.
> which removes the financial incentive for surgeons to do better and prevents bad surgeons from being weeeded out of the market
This is absolutely not why the 'doctors unions' fight against performance statistics. Can't you people think of nothing else than money ?
Or even some form of RFID tagging and a scan wand.
It's the only time in my theatre career I might have maybe indirectly saved a life.
Though honestly, I’m sure you saved many other lives directly or not by theater that speaks to people, that they can identify with.
The article mentions that counting is standard procedure, so hopefully this is how it works everywhere. It definitely seems like having someone who isn't the surgeon doing the counting would be the way to go. The surgeon is already very focused and it's easier to say "I'm sure I didn't leave anything" when someone else isn't telling you otherwise.
Swabs and towels tend to come in pre-prepared packs, so the nurses have another source of truth. Any mismatch between the preprepared count, running count during the operation, and actual swabs/towels laid out at the end is a serious cause for concern. You will not close up a patient if there is a mismatch.
At least it would be more useful than the system they use for self checkouts at my local supermarket. "Did you forget to scan something in your trolley?" Yes, it's my child.
For further reading the Health Services Safety Investigations Body in the UK (like the NTSB but for healthcare incidents is the best worst analogy) looked at retained foreign objects and published in 2024: https://www.hssib.org.uk/patient-safety-investigations/retai...
[1]: https://www.england.nhs.uk/long-read/provisional-publication... [2]: https://digital.nhs.uk/data-and-information/publications/sta...
littlexsparkee•2d ago