I read this Wired article about checklists written by Dr Cosima Gretton (a newly qualified Doctor working in the NHS) (follow her on Twitter) and wasn’t at all surprised. I may have had a mobile with me and always on for the last 20+ years but my advancing years mean I’m still a mobile immigrant and probably can’t even begin to imagine how confusing it must be for the BornMobile generation (who have always existed in a world where everyone is connected) to finish up at medical school and find themselves having to use Fax Machines and interact with 19 different software programmes to work in a ‘world class’ teaching hospital across the bridge from the Houses of Parliament:
It’s really no wonder checklists fail to make sense when viewed from on top of such a spaghetti style mess of competing IT non-systems and priorities, the NHS may not be yet using checklists appropriately (eg. those idiotic A&E kiosks!) but let’s not let this completely cloud our perspective and let’s let Patients and Carers also use them.
“Since the aviation industry improved its safety record in the 80s and 90s -in part through the use of checklists by pilots – similar methods have been attempted in healthcare. In 1999, the Institute of Medicine, a non-governmental US body, published a report, To Err is Human, which was the first admission of the death and disease caused by medical error. Since then the focus across all aspects of medicine has been on imitating aviation in reporting errors in an attempt to create the “black box” of healthcare“
“In 2001, Peter Pronovost, a specialist in intensive care at Johns Hopkins Hospital in Baltimore in the US, created a five-step checklist for placing a catheter in a large vein of patients. The checklist included simple instructions such as “Wash your hands with soap” and “Wear a sterile mask, hat, gown and gloves”. It reduced infection rates from 2.7 per 1,000 patients to zero inside three months, and is estimated to have saved 1,500 lives across the Michigan hospitals in which it was implemented. Since then, checklists have proliferated in every aspect of healthcare“
“However, there’s a problem with the overuse of checklists. Checklists oversimplify medicine. They might work for carrying out procedures and remembering simple sequences of actions, but not when managing the complexity of a 95-year-old with heart failure and multiple co-morbidities who wishes to die in peace. Patients’ psychology and physiology are complex and constantly changing, and we understand too little. They require systems with flexibility and adaptation. Checklists can’t simplify the inherent complexity of medicine“
The idea that a checklist output is the same as a diagnosis is such a common misunderstanding Doctors have about checklists. I’ve been working around the clock recently turning a paper based checklist developed over the last 30 years by one of the world’s most pre-eminant Consultant Paediatricians into a secure online tool that will be made available free-of-charge to help Parents the world over who have children suffering with allergies and long term conditions. From this experience let me assure you understanding the output of this checklist/questionnaire is not creating ‘paint by numbers medicine’ but helping Patients and Carers share their stories, making better use of the skills of highly qualified Doctors and helping less experienced Doctors see when they’re clearly out of their depth and struggling to manage things with too little information and not enough understanding/experience.
A good example of the problem we have when we don’t let Patients contribute to their EHR is that in my work conducting audits etc I’ve personally reviewed the electronic records of hundreds of very elderly Patients in hospitals and although advance care directive initiatives are at last happening I have yet to ever see information explaining how the Patient wishes to die listed in an electronic billing/CMA database. Most Patients don’t even get to see their EHR never mind the capacity to post their “wishes to die in peace” to that provider held record.
Related: Watch David Doherty explains Mobile Video Consulting best practice at Doctors 2.0 in Paris