Boxing clever
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c514 (Published 27 January 2010) Cite this as: BMJ 2010;340:c514
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Its worrying that those furthest removed from day-to-day surgical
practice seem to be embracing the new WHO surgical checklist most
enthusiastically. NHS administrators and hospital managers for example,
desperate to get mortality and morbidity figures down by the cheapest
possible means, prefer the appeal of tick-boxes over improving surgical
training or confronting the consequences of EWTD. Thus there's a certain
irony that Atul Gawande's book 'The Checklist Manifesto' is reviewed by a
physician rather than a coalface surgeon. In espousing its philosophy, the
reviewer, Dr John Quin, omits to tell us that its author is far from
independent, being one of the participants in the NEJM study (Haynes, A.B
et al 2009 360 491-99) which actually quotes improvements in mortality of
just 0.7% and in morbidity of 7% ( NOT the seriously misleading 47% and
36% respectively quoted in the review).
There's barely a jot of hard evidence for Gwande's proposal that the
WHO surgical checklist is appropriate for modern Western surgical
practice. In the original NEJM article which showed such relatively tiny
overall improvements in outcomes, 3rd world hospitals were included (but
unidentifiable) where safety parameters improved from levels unthinkable
in European or American practice (eg swab counts rose from 0% to 92% and
airway evaluations from 0.5% to 94%).
Only 2 weeks earlier in the BMJ, Vats A. and colleagues stated in
respect of their UK pilot study "at our hospital, we found no significant
change in overall morbidity or mortality". They also emphasised the
difficulties in maintaining use of the checklist by surgical teams after
removal of the scrutiny involved during their research.
The fact is that the checklist has been promoted internationally by a
supranational quango (the WHO) and imposed on us in the UK by a national
quango (the National Patient Safety Agency). There is no question of the
need to improve operative procedures and their outcomes but local lack of
enthusiasm for the checklist is most likely an expression of a belief that
the process is little more than a distraction. It does nothing to address
the most pressing issue of ensuring that the surgeon is adequate for the
task and is no more likely to identify incompetency than revalidation is
to uncover the next Harold Shipman.
Competing interests:
None declared
Competing interests: No competing interests
Is an expensive solution better than a cheap one?
I realize that simple cheap ways to improve the results of
surgery is an insult to the profession of surgery, which as
we all know always delivers the best possible care and never
makes mistakes.
But that is no excuse for mangling the argument and the
evidence for checklists as Peter Mahaffey does.
Gawande is very clear that the checklist is not about
identifying incompetence or finding someone to blame for
mistakes. The analogy with pilots is illuminating. Airlines
have a more mature attitude to safety across the board than
hospitals, from how dangerous incidents are reported (in a
blame-free way designed to encourage the development of
improved processes before near misses turn to real deaths)
to pre-flight checklists (designed not to highlight
incompetent pilots but to ensure that the competent pilots
don't miss key steps in a complex environment).
Even skilled and experienced people make mistakes in complex
environments: skill, training and experience are not enough
to ensure best practice is always followed.
Mahaffey also tries to belittle the evidence by using
absolute rather than relative improvement. Perhaps some
ambiguity can be avoided by quoting absolute numbers rather
than (always confusing) percentages. The evidence equates
the approximately the following: for every 10,000 surgical
procedures, the rate of complication falls from 1,100 to 700
(thats 400 fewer people with complications) and the
mortality rate falls from 150 to 80 (that's 70 fewer
deaths). Perhaps this 0.7% improvement is insignificant, but
I doubt that is how the public would see it.
The assertion that enthusiasm for checklists is a feature of
how far away the reviews is from surgery is also far of the
mark. Checklists have led to even bigger improvements in
other areas of medicine. Gawande quotes even more dramatic
improvements in areas such as infection rates after central
line insertion in North American ICUs.
The pervasive belief that medicine is a craft profession
where neither quality or efficiency can be improved without
big spending is a major reason why improvement is hard to
achieve. But there are (sometimes) cheap and easy ways to
make things better and a profession that was really focussed
on patients would not put up so much resistance to them.
Competing interests:
None declared
Competing interests: No competing interests