Not Just Great Ideas: The Surgical Safety Checklist and the ICU Walker

Deepa, you took the words right out of my mouth! Never underestimate the power of a checklist...

I'm a last minute packer. I usually don't open my suitcase and fill it until the night before I leave for a trip. Sometimes, I only give myself an hour before I have to bolt out the door. Because I tend to over-pack, bringing at least one extra set of clothes for unexpected events, forgetting something in the chaos of my packing process happens easily and often. After forgetting my cell phone charger, my headphones, my jump drive, my blue jacket, my laptop sleeve, a DVD, my tooth brush, and many other miscellaneous important items on various trips, I decided that I had to create a checklist.

I opened up Word and created a checklist that so far, has helped tremendously. Ever since I've created it, I haven't forgotten anything! Click here to see the list.

Years of psychological and human factors research have proven that we are fallible. As hard as we try or hate to admit it, human errors are bound to happen. So, why pretend it never happens? Especially when some kinds of forgetting endanger others and can lead to dire consequences. Several industries have transformed themselves with human errors in mind. The airline industry is a favorite example. As a result of air craft design, regulation, the use of checklists, and other systems designs, we are almost guaranteed to reach our final destination safely. According to data collected between 2000 and 2005, the chances of a fatality on a US airline flight was one in 22.8 million (1).

Health care is slowly following in the footsteps of the airline industry. Several interventions from preventing central line infections to preventing pressure ulcers capture best practices and allow for measurement of progress-- all to achieve desired results. Click here to see other such interventions.

At IHI's 20th Annual National Forum, Don Berwick and Atul Gawande made an announcement about the enormous potential of the WHO Surgical Safety Checklist to save lives. Click here to watch! A paper published in the New England Journal of Medicine, suggests that implementation of the checklist can reduce inpatient complications and prevent deaths. In a one year pilot study conducted in eight locations from across the world, inpatient complications were reduced from 11% to 7% and the rate of death declined from 1.5% to 0.8%.

Here are some more numbers: It is estimated that 234 million operations are performed globally every year. With the observed reduction in inpatient complications and deaths, the checklist could prevent 9,360,000 complications and 1,638,000 deaths (numbers calculated manually, not reported in paper). On top of that, the surgical safety checklist is a one page document with 19 steps-- a rather inexpensive intervention that is readily adoptable. That's amazing potential to save lives!



Checklists aren't the only type of systems redesign that can help improve health care. Taking a note from the airline industry again, there many processes in health care that can be redesigned and standardized to absorb human errors and make safe execution the only option (2). For example, buttons in the cockpit are color coded, of specific shapes, and can be manipulated in a standardized way. A cockpit is designed to be user-friendly. Shouldn't health care be user-friendly?

Let's look at a specific health care process: getting intensive care patients out of bed and walking. Research conducted by Dr. Dale Needham of Johns Hopkins School of Medicine has shown that ICU patients benefit from getting out of bed and walking from time to time (3). These benefits include preventing muscle atrophy, improving lung function, and even decreasing the length of ICU or hospital stay. But, as you can imagine, this is not an easy task. Most ICU patients are weak and are hooked up to several devices. The current process just to prepare for walking takes 40 minutes, two nurses, and probably great dissatisfaction from patients-- who would want to get out of bed if it took 40 minutes? On top of walking with the chaos of cords and wires at your side, this kind of venturing out of bed requires a respiratory therapist and someone to follow the patient closely with a wheelchair in case the patient slips or needs to sit down immediately.

This process clearly could use some systems redesign. Accepting the challenge were eight biomedical engineering undergraduate students at Johns Hopkins University (JHU). They decided to design a walker that would allow ICU patients to get out of bed and walk around safely. Joshua Lerman (JHU '08) and his team first conducted a little research and collected about 50 objectives from doctors, nurses, and patients including safety of the innovation, ease of use, comfort, and maintenance. The improvement innovation also had to be self-contained, accommodate several medical devices, and fit in typical hospital corridors. Patient safety was their primary objective.

After several draft ideas including large adjustments such as, avoiding stress on the wires connecting the patient to medical equipment, and minute design details such as, the type of cloth used for the built-in seat of the walker, Josh Lerman and his team finalized their design. The ICU walker, or more formally known as the ICU Mover Aid, consists of two parts: 1) a streamlined tower that consolidated all necessary life support equipment and 2) a walker/wheelchair combination.



The final product reduces the chaos of several life support devices attached to the patient making it safer to walk, requires only a respiratory therapist to monitor and walk with the tower and a physical therapist to stand behind the patient and walker, and can be easily maneuvered through typical hospital corridors. The ICU walkers are now in use at Johns Hopkins.

I'm continually inspired by the ICU walker project because the improvement was created by students. As Dr. Berwick mentioned in his 2008 Forum Speech, hospitals have at least a 100 processes that each have best practices. While learning about patient safety and quality improvement is important, I don't think students have to wait until after completion of professional school to become a part of improvement work. Students are sets of fresh and enthusiastic eyes-- why not participate in improvement now?

IHI Open School leaders, Andy Carson-Stevens from Cardiff University in Wales and Rachel Fesperman of University of North Carolina- Chapel Hill, while at the IHI Open School Congress on January 10th proposed a way for students to get involved in the implementation and adoption of the WHO Surgical Safety Checklist. Medical students around the world participate in a surgical clerkship where they have the opportunity to observe and sometimes participate in the operating room. Andy and Rachel believe that these medical students can be mobilized for quality improvement.

These medical students can take ownership of the WHO Surgical Safety Checklist (or an institution's own surgical safety checklist) by memorizing it and taking notes on adherence to the checklist. Not only will the medical students be indoctrinated in best surgical safety practices for their own future careers, but they will become an army of data collectors-- measuring the impact of the implementation of the checklist from quantitative patient outcome results to more qualitative communication improvements within the surgical team. Other professional students can also easily get involved by helping with the analysis of data and developing suggestions for improvement.

There's a quote by Margaret Mead that is immortalized on the walls of our offices just above my desk and it reads, "Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has."

The WHO Surgical Safety Checklist and the ICU Walker are not just great ideas for health care, but are improvement projects of great potential that if quickly adopted can change the world of health care. Any particular process in health care that you think desperately needs attention? What are some other great improvement projects? How can students get involved?

1. USA Today on Airline Safety

2. Leape, Lucian. Error in Medicine. JAMA. Volume 272(23), 21 December 1994, pp 1851-1857.

3. The New York Times on Dr. Dale Needham's research on walking and ICU care

More Information about the WHO Surgical Safety Checklist on IHI.org

Other articles about the WHO Surgical Safety Checklist and the ICU Walker:
The Washington Post on WHO Surgical Safety Checklist
USA Today on WHO Surgical Safety Checklist
The New York Times on WHO Surgical Safety Checklist
The New York Times on ICU Walker

Video of Atul Gawande Explaining the WHO Surgical Safety Checklist

Cutting down on surgical complications? Easy.

A new checklist -- yes, that thing you use when you're packing for a trip or moving house -- can cut surgical deaths by nearly one-half and complications by more than a third.

Eight hospitals around the world piloted the World Health Organization's surgical safety checklist between October 2007 and September 2008. The results were published this week in the New England Journal of Medicine.

From the Washington Post story:

The low-cost, low-tech intervention tested in eight hospitals around the globe could have enormous financial implications, as well. If every operating room in the United States adopted the surgical checklist, the nation could save between $15 billion and $25 billion a year on the costs of treating avoidable complications, according to calculations by the authors.

In the one-year pilot study involving 7,600 patients, the hospitals saw the rate of serious complications fall from 11 percent to 7 percent. Inpatient deaths declined by more than 40 percent overall, with the most drastic reductions occurring in hospitals with fewer resources.

The checklist isn't complicated. It includes 19 basic steps such as counting sponges and confirming the patient's known allergies. It saves lives, it's cheap to implement, and it's available today to every hospital in the world.

Is your hospital planning to use it?

IHI Open School featured in The Boston Globe's health blog

Ishani Ganguli, a third-year student at Harvard Med, blogs this week about the IHI Open School's first Chapter Congress:

On Saturday, I observed a rare convergence of health professional students outside hospital walls.

It was the first annual face-to-face meeting of the Institute for Healthcare Improvement's Open School for Health Professions -- a hub of online courses, case studies, and discussion forums that empowers students to work on quality improvement issues. The school launched last fall and has already registered 9,000 students, with more than 78 school and hospital-based chapters in 25 states and 10 countries, director Jill Duncan told me.

Check out Ishani's full post on Short White Coat, a blog about learning to be a doctor. It's hosted by The Boston Globe's White Coat Notes health blog.

New Year's Resolutions

Happy New Year! While New Year's Eve means for most a countdown to midnight, a toast of champagne (sparkling cider for the little ones), hugs and kisses with friends and family, and hopefully a better rendition of Auld Lang Syne than what I heard last night, let's consider new year's resolutions...

Midnight on December 31st seems like such an arbitrary moment in time, yet it holds so much meaning for everyone. Is the new year a new beginning? A second chance? A redo, restart, or reboot? Last night, my family and I sat on Hollywood Beach along with at least 300 perfect strangers to watch a captivating dance performance and countdown to the new year. Many families brought with them bottles of champagne to the beach to celebrate the new year. Perhaps December 31st didn't feel any different from December 30th, June 15th, or April 8th, so we brought water. My mind was completely fixated on the dance performance-- Abakua, an Afro-Latin Dance Company, I couldn't even imagine what that would look like. But then my dance musings were suddenly interrupted by the city commissioner of Hollywood. He kicked off the dance show with a hearty, "I wish you all a Happy and Healthy New Year." A happy and healthy new year, huh?

I'll admit that the Abakua dancers distracted me from new year's resolutions and thoughts of health for their two hour show. The dancers were amazing and proved that a fusion of two dance cultures was not as difficult as I initially thought. But when their show came to a close and we were left to dance around in the sand in the last twenty minutes of 2008 waiting for midnight, I began to wonder about the sudden emphasis on health in the new year. Did the city commissioner mention health because the average age of the audience was probably over 40 and the majority of the population was probably snowbirds from New York? Or was it the new emphasis on health reform as brought about by the recent Presidential elections? With the struggling economy, maybe those escalating health care costs are finally looking debilitating? Or maybe on a more individual level, people always want to lose weight. Conversations around us all contained snippets of "exercise more", "eat healthy", "lose X pounds". Taking a quick look at USA.gov's list of popular new year's resolutions, seven out of thirteen of them are health-related.

Whether or not this new year means a blank slate or a redo, we can take this opportunity to embrace the atmosphere of change, revisit our current health situation at all levels, and take some positive actions. In my personal realm of fitness, I'm going to try to vary my exercise routine, start to include some weight training, and push myself a little harder aerobically. My parents are going to try to go to our local gym at least once a week. My sister is going to work on eating less cookies (something I should actually work on too!).

Health changes are occurring on a larger scale as well. At our National Forum, IHI has laid out a new initiative called The IHI Improvement Map to help hospitals and health systems achieve positive change this year and in years to come in health care delivery.

While it may be an exaggeration to say that health systems are stuck in a bit of a quagmire, the Improvement Map hopes to help hospitals navigate and find those reliable routes of improvement. The 12 changes launched through the 100,000 Lives and 5 Million Lives Campaigns are a few routes and IHI is now expanding that list to include three new routes: the WHO Surgical Safety Checklist, a Catheter-Associated Urinary Tract Infections bundle, and a CFO package to address finances and quality. The list will continue to expand and develop as we learn of new routes to the best outcomes. Click here to learn more as there is something for everyone.

So, as you take today to think about your new year's resolutions and the new year, let me take this opportunity to echo the city commissioner's sentiments: Cheers to a happy, and most of all, healthy new year!

What are some of your healthy new year's resolutions (personal or at a larger level)?

How much patient safety is too much?

Recently I read an interesting article about patient safety. The author discussed the growing trend of involving patient's in their care, for example, by asking patients to 'mark' the site of surgery. Is it too much, he asks? Are these patient safety measures being implemented to protect providers against malpractice suits? The author notes,

True, serious medical mistakes do happen. I heard a rumor that a New York doctor accidentally left a barbecue grill inside a patient. Another doctor transplanted a viable liver into the wrong patient's head. Malpractice lawsuits have forced doctors to take unusual measures. Before my wife was wheeled into the operating room at the surgical center, she was given a Magic Marker and told to mark the location of her chemo port with an X. This seemed rather pointless given that the port was clearly poking out of her chest ... On another gurney, a patient waiting to have his knee scoped was asked to write "yes" on the appropriate knee... Maybe this sort of patient participation cuts down on surgical mistakes. Maybe it just reduces doctors' liability. I asked the medical staff. They said it was just one more way of making sure everything went according to plan... Malpractice litigation must be worse than I thought. Do expectant mothers have to draw these helpful diagrams: "Baby comes out here" with an arrow?

The patient safety measure the author is referring to is of course, Universal Protocol, which ensures that marking the procedure site allows staff to identify (without ambiguity) the intended site for the procedure. I'm not sure how many hospitals actually require the patient do the marking, but I am aware of having patients involved in the process. Many of these patient safety measures we hear about, including Universal Protocol, have come about because of cases where hospital staff have made mistakes and done surgery on the wrong limb etc.

So has patient safety gone too far? I don't think so. If we weigh the burden of implementing these patient safety measures against the number of lives that have been saved and the numbers of medical errors which have been prevented - I tend to think we're on the right track. It seems that the direction patient safety is heading these days, we'll be seeing a lot more patient involvement in their care. Involving patients in this manner is not taking the duty away from healthcare providers, but in fact, it's empowering patient's to be partners in their care... and that can't be a bad thing, right?

Collective Intelligence: Google Can Do It. What Can Health Care Do?

Wikipedia, Youtube, Facebook, blogs...how many times a day do you visit these pages? Don't know something? Wiki it. Want to watch something? Youtube it. Think you know someone? Facebook him. Want to voice an opinion? Blog it. The internet has become a very powerful source of information and better yet, it's a shared source of information that exhibits boundarilessness and speed.

But that's not all. Recent technologies and initiatives have harnessed the actual use of the internet as a form of collective intelligence, a form of group intelligence that results from the collaboration or competition of individuals. Like the cliche, "There is no "I" in Team," collective intelligence values in the input of all members for the good of the whole (information provided by Wikipedia.org).

Several of the websites mentioned above take advantage of this very concept. Wikipedia is an open source collaborative that allows anyone and everyone to contribute encyclopedia entries on just about everything. Fact checking and reliability is also in the hands of anyone and everyone around the world. While the title Youtube may suggest vanity in creating your own 15 minutes of fame, it is also a shared pool that is accessible to everyone. Perhaps Wetube is a more accurate name.

Collective intelligence has three main facets: cooperation, coordination, and cognition. Wikipedia, Youtube, and Facebook have thrived on cooperation and coordination by creating virtual communities around shared interests and widely spreading information. Only recently has the cognition facet of collective intelligence begun to take form.

The cognition facet of collective intelligence allows for the study of behaviors and capturing the force of those behaviors. This facet transforms the internet beyond a shared pool of knowledge into a powerful tool for social change. Let's consider some examples.

In September, Science published an article about reCAPTCHA, a free CAPTCHA service that helps to digitize books. A CAPTCHA is a Completely Automated Public Turing test to tell Computers and Humans Apart. We have actually all come across CAPTCHAs- they are used by several websites to verify that the entity filling out a web form is a person and not a machine. Does retyping a distorted jumble of letters and numbers sound familiar?



Consider this. Suppose it take 10 seconds for each person to retype the jumbled combination, and that there are millions of people on the internet at any given time of the day. In this context, the minuscule 10 seconds of "wasted time", in aggregate becomes an enormous untapped pool of productive man hours.

Now, consider this. The Internet Archive and Google Books Project are currently digitizing books with a crew of expert transcribers and sophisticated computers. Computers are able to do most of the work, but when it comes to difficult to read yellowed distorted texts, computers are only able to decipher about 20% of the words accurately. Human transcribers are over 99% accurate, but hiring them can be expensive.

Combining the large pool of productive man hours and the great need for humans to perform what machines can't, you get reCAPTCHA. reCAPTCHA is being used by 40,000 websites and demonstrates that old printed material can be transcribed word by word by having people solve CAPTCHAs throughout the web with accuracy over 99%. More importantly, Luis von Ahn and his reCAPTCHA technology are capitalizing on internet behaviors to help digitize books and make human knowledge more accessible. Thank you collective intelligence.

Can the health care industry take advantage of collective intelligence too? Google has taken a stab at it. Google has become the go-to gateway of information. And as we use it to research information for our specific purposes, Google can use our "Google it" attitude to collect information about us! In a unique pairing of the internet and public health, Google has been able to track the spread of influenza 10 days faster than the Centers for Disease Control and Prevention (CDC) by tracking the number of searches for words like "flu", "flu symptoms", and "influenza".

Source: New York Times

Since the data collected by the CDC is dependent on information collected by patients interacting with health care through doctor visits and lab tests, the CDC's ability to follow flu outbreaks is slower. More information about the flu trend that Google.org, Google's philanthropic division, is tracking can be found at www.google.org/flutrends/.

Google has helped to prove that health care can benefit from the power of collective intelligence. What else is possible? Please share your thoughts!

"I Watch the Line"

Two weeks ago, the IHI Open School talked to Dr. Peter Pronovost about checklists and how checklists could help in standardizing the practice of medicine and reduce medical errors in the IHI Open School On Call Series.

One such checklist or bundle at the IHI 5 Million Lives Campaign is to prevent central line infections. As Dr. Pronovost mentioned on the call, central lines are used to feed patients drugs, nutrients, and other important fluids. Because this catheter is a foreign object placed in the body, it is prone to infection, which is highly dangerous for the patient. Years ago, central line infections were thought to be an inevitable medical hazard. But, after careful study, a central line bundle was created to reduce and eliminate central line infections. This bundle includes things as simple as hand washing and maintaining a sterile environment. Click here to download Dr. Pronovost's Central Line Infection Checklist (the checklist is also available at www.ihi.org).

Several hospitals have quickly adopted such checklists and have achieved remarkable results. Below is a Youtube video celebrating the Johns Hopkins and Adventist Health System central line research initiative. This video just goes to show that checklists are not only useful, but can be fun too! Enjoy!

Thank you Frank Federico for sharing this with us!