Checklists and bureaucracy

Here’s an article about using checklists in medicine by surgeon and author Atul Gawande. He also wrote a book on the subject called The Checklist Manifesto.

The article mentions a landmark event in the development of airplanes. During an early demonstration of the machine that would become the B-17, a prototype crashed shortly after takeoff. The Boeing Company responded by developing checklists for the pilots, so they did not have to commit to memory all the steps required to operate such a complex machine.

These checklists have become an essential part of aviation. The Cessna 172 I flew a couple of decades ago has a bunch of them. They are printed in large type on a sheaf of sturdy plastic-laminated cards bound together with a big metal keyring. They’re in a pocket in the left door of the airplane, easily found by feel by the pilot’s hand that doesn’t need to operate the throttle or other controls.

For example, the checklist labeled Before Engine Start has these steps:

  • Seatbelts / Shoulder Harness:  Fastened
  • Brakes: Test & Set
  • Fuel Selector: Both
  • Fuel Shutoff Valve: On (In)
  • Circuit Breakers: Check
  • Beacon: On
  • Avionics Switch: Off
  • Master Switch: On
  • Throttle: Open 1/4 inch
  • Mixture: Idle Cutoff
  • Aux Pump: On
  • Mixture Rich 3-5 GPH: Cut Off
  • Aux Pump: Off
  • Propeller Area: Clear

That’s a lot of stuff! Cessna 172s are simple airplanes. They don’t have retractable wheels. They only have one four-cylinder engine. But they still have many tasks for the pilot to remember. For example, there’s a fuel tank in each wing, and a fuel-selector valve. If the pilot forgets to set that fuel selector to use both tanks, she might be making an unplanned landing in the near future.  This checklist begins and ends with human safety: Buckle up! Make sure nobody’s walking near the prop!

The checklist is not an operators’ manual or an essay on safety. Some of the items on the list (what is mixture?) don’t mean anything obvious to untrained people.  It’s not something the pilot is expected to memorize; quite the opposite.

It is not a three-part form the pilot has to fill out and file with the local control tower. Here’s my point. The medical-procedure checklists mentioned in Dr. Gawande’s work are forms. They are expected to be filed in patients’ folders.

Why?

Why can’t they be the hospital equivalent of laminated cards? Every patient room has several displays in it. Why can’t the checklist for inserting an intravenous line be displayed on one of those monitors, or even shown on a poster stuck to the wall? A pilot gets the benefit of the checklist by following it, not by proving she followed it.

In many hospitals, every bit of equipment gets bleeped by a barcode scanner before it’s used. Why couldn’t the relevant checklist for the item bleeped be scrolled up on a screen?

Why can’t the infection control protocol be posted on a card by a patient’s room? Before entering,

  1. Clean your hands
  2. Put on a gown
  3. Put on a facemask
  4. Put on gloves

Hospitals strive to enforce checklists by making them into medical records. I wonder if that’s counterproductive? Why not focus on making them visible and easy to follow, like Cessna checklists?

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