Simple things that make a difference to patient safety

A message to all physicians from AMA President Peter W. Carmel, MD.

By Peter W. Carmel, MDis a pediatric neurosurgeon in Newark, N.J., and is immediate past president of the AMA. Posted Aug. 1, 2011.

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Back in 2007, a Harvard Medical School surgeon wrote an article in The New Yorker magazine that raised a lot of eyebrows. If surgery units would follow a very simple checklist, wrote Atul Gawande, MD, it would both save lives and lessen complications.

Such a checklist was being promoted and used by Johns Hopkins critical care specialist Peter Pronovost, MD, he said, and it had made a remarkable difference.

Initially, the surgical community received the article with disbelief, derision and a lot of defensiveness. Yet there were those who intuitively saw the potential benefits of checklists. My hospital was one that signed on. Today, we use checklists routinely.

I am a big fan of these simple checklists. They are designed to make sure that in our focus on the complex we don't overlook the obvious. In my own work at the New Jersey Medical School, for example, every surgery involves three checklists:

  • The first list is reviewed before the surgery. We confirm things such as whether the patient has confirmed his or her identity, whether the site is marked, and whether the anesthesia machine and medications have been checked.
  • The second takes place at the "time out" after the patient is asleep but before the surgery begins. Again we confirm the patient's name, the procedure and surgery site. We review anticipated critical events such as estimated time, steps, anticipated blood loss, sterility and presence of essential imaging.
  • When the surgery is over but before the patient leaves the operating arena, we go through points on the third checklist. This time, we confirm the procedure, the instrument, and sponge and needle counts, and list key concerns for recovery and the like.

None of these questions requires a fellowship in surgery or anesthesiology, but all of them are important to the success of the procedure. They are focused, brief, actionable, verbal, collaborative -- and tested. They make a surgical team's life easier. More important, they have been proven to reduce surgical morbidity and mortality significantly.

The checklists are a simple way to keep our highly trained specialists focused on the complex procedures only they understand, without losing sight of the equally important fundamentals of taking care of patients during surgery.

According to the Centers for Disease Control and Prevention, there are somewhere upwards of 53 million outpatient and 46 million inpatient surgeries in the U.S. every year. Just think: If we can nudge the quality needle upward even a tiny bit, we can make a difference in many people's lives.

Even just one preventable error is one too many.

Today, Dr. Gawande leads the World Health Organization's "Safe Surgery Saves Lives" program. His checklists are used in more than 3,000 hospitals in every part of the globe, including my own.

The checklists do not "dumb down" the practice of medicine -- nor are they a magic wand. Instead they re-establish positive habit patterns of highly skilled surgeons, anesthesiologists and surgical teams.

In their own way, the checklists actually underscore the complexity of what we do. Their success reflects the need to keep things as simple as possible where we can, in the midst of our very complicated world of science and technology.

As Dr. Gawande points out in his book The Checklist Manifesto -- which I heartily recommend -- something as simple as a checklist is a hard sell to a profession like ours. However, checklists are used routinely by pilots and in a variety of other industries. They are used because they work.

I, for one, am all for anything that improves safety, simplifies my job and keeps me focused on what only I can do. That's why I believe in checklists. That is also why I appreciate the AMA's leadership and support in these areas.

The AMA has long been on the forefront in working toward medical quality and patient safety. In 1997, the AMA was a leader in organizing the National Patient Safety Foundation, the NPSF.

Later, the AMA established the Physicians Consortium for Performance Improvement, or PCPI, a national, physician-led initiative dedicated to improving patient health and safety by developing, testing and implementing evidence-based performance measures for use at the point of care. Already, 131 individual quality measures have been developed and are used for claims-based reporting. Both the NPSF and the PCPI are taking a long and careful look at the steps that are involved in patient care -- and make sure that they are safe and evidence-based.

At the same time, it is vital that physicians are not bogged down in documentation minutiae. It is easy for the rule makers to "pile on" extra steps that make little or no improvement in patient care.

The AMA has gone to bat in recent weeks and months to keep physicians from having to deal with extraneous paperwork that would only take up time and do little to protect patients.

When CMS decided that every laboratory requisition had to be physically signed by a physician, the AMA had those rules changed. The AMA also had a hand in stopping CMS' "Stealth Shoppers" program that planned to "test" physicians by having people pose as Medicare and Medicaid patients -- only to take up time of already busy personnel and crowding out existing patients. This was a bad idea for office staff, patients and physicians.

Our jobs are tough enough. It is good to know that we have at our disposal simple tools like checklists and support organizations like the AMA watching our backs.

We cannot do it alone.

Peter W. Carmel, MD is a pediatric neurosurgeon in Newark, N.J., and is immediate past president of the AMA.

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