NPR’s Morning Edition did a great piece with surgeon and author Atul Gawande. Gawande discussed his own experience where doctors were hesitant to use checklists, probably because of perceptions that it was admitting weakness. After requiring a group of doctors to use checklists, 80% of them said they thought they were useful. When the same group was asked if they would want checklists used if they were having an operation, 94% said yes.

One of the most powerful statements in the interview:

I have not gotten through a week of surgery where the checklist has not caught a problem.

Brian Chiarizia and Alex Hussain are roaming the floor, attending keynotes and chatting up their friends in the home medical equipment (HME) industry.

Medtrade is celebrating its 30th anniversary and has a large following of HME manufacturers, vendors and suppliers.

The Consumer Union, in a report published in April of 2009, revealed that virtually no headway has been made relative to improving this statistic in the past decade. My response and yours should be something akin to “you have GOT to be kidding me!” Now, don’t get me wrong. I am aware that the healthcare system is complex and made up of thousands of “Mom and Pop” collaborators that must interact and cooperate and remain profitable, but pppuuullleeeaaasseee! When hospitals conclude that paying hush money is preferable to solving problems and paying for efforts to NOT kill patients, then the problems take on an air of criminal neglect of such magnitude that Congress itself needs to step in.

The problem is not just with the Walter Reed’s of the world or other VA institutions wherein we must choose between doing the right thing by our vets versus buying a new weapons toy, but even venerable institutions such as Duke Medical Center, Cedar Sinai, and the University of Virginia Hospital are cited for errors that can and must be eliminated. Notable and high-profile problems with heparin, tainted surgical tools (in over 3600 surgeries across three years), and multiple deaths potentially due to mistyped donor organs are pervasive, and yet hospitals continue to conduct business as usual.

Tools for identifying and correcting human errors or, at the least, managing the resultant impact of such errors are available and do indeed work. This is a case of having the tools at hand. Why the hesitation? Maybe it is because of the difficulty in quantifying the ROI associated with events that do not happen because the intervention worked.  Measuring the benefits of an intervention can be difficult, requiring an acceptance that errors would have happened had the intervention not occurred. The situation is analogous to the past administration trying to justify its expenditures and actions by alluding to the terrorist events that were precluded by their actions. There is a paucity of evidence…in fact, a complete lack of it. The very fact that nothing occurred in and of itself undermines the very evidence needed to justify the cost.

So how does one circumvent this illogical trap? One approach is to aggregate the costs associated with the class of problem both prior to the intervention and after the intervention. Since there are no guarantees that the intervention will work, it requires an act of faith for the period of the intervention. Another approach is to estimate the probability and costs of certain events that will be found and corrected during the intervention. This again requires an act of faith to spend the funds necessary to identify and correct the problem to begin with, and perhaps the willingness to identify the problem, NOT correct it, and then see whether it occurs. This would be the “Jackass the Movie” approach to human error management.

Whatever the approach, the passage of most of a decade without addressing this problem represents the worst that healthcare has to offer and, certainly, does not fulfill the medical credo of “first, do no harm.”