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Medical Advice from Atul Gawande

Surgeon, writer prescribes better hospital care checklist


Surgeon Atul Gawande says that using a simple checklist significantly reduced infections and surgically related deaths in eight hospitals where it was tested, resulting in a 36 percent decrease in postoperative infections and a 47 percent decrease in deaths. Photo by Kalman Zabarsky

The surgical team and the patient are ready in the OR. Members go down the list:

• Before anesthesia — confirm patient identity, incision site, surgical procedure, consent
• Before incision — team members identify themselves by name and role
• Before patient leaves operating room — confirm procedure, identify key concerns for patient recovery and management

These actions, part of a 2-minute, 19-item inventory, would seem to be basic accounting for a surgical procedure. Yet surgeon, public health policy researcher, and writer Atul Gawande says these and other standard checks for safety before, during, and after surgery are not universal. In fact, they are not standard in most hospitals.

Gawande, the author of several New York Times best-selling books on medical and surgical practice, spoke on April 14 to more than 100 School of Medicine and School of Management students, faculty, alumni, and guests at the SMG auditorium.

An associate professor of surgery at Harvard Medical School and a general and endocrine surgeon at Brigham and Women’s Hospital and the Dana-Farber Cancer Institute, Gawande was joined by Ravin Davidoff, a MED professor of medicine and chief medical officer of Boston Medical Center, and Janet Porter, chief operating officer of the Dana-Farber Cancer Institute.

Gawande, who is the director of the World Health Organization’s Global Challenge for Safer Surgical Care, reported that using a simple checklist has significantly reduced the number of infections and surgically related deaths in eight hospitals where it was tested, ranging from a major academic medical center in the United States to a rural facility in Tanzania. Gawande said the hospitals saw a 36 percent decrease in postoperative infections and a 47 percent decrease in deaths.

“Surgical complications account for 150,000 deaths per year in this country,” said Gawande, author of The Checklist Manifesto: How to Get Things Right (Metropolitan Books, 2009). “Half of them are avoidable.”

He noted that airline pilots methodically use checklists to ensure flight safety and builders of skyscrapers use them to build complex structures safely. “The highest trained professionals in these fields use simple checklists,” he said.

Gawande’s central argument is that modern medical and surgical care is far too complex for one person to do it all and “get it right.”

“We have 13,000 diagnoses, 6,000 drugs that we use to treat our patients, and 4,000 medical and surgical procedures,” he said. “Cardiovascular disease has outstripped all others as the number-one disease in the world, and it requires much more complex interventions.”

Davidoff, whose Boston Medical Center uses a similar but more extensive checklist method, echoed this opinion. “Unlike when I was a resident in the 1970s and my chief told me, ‘Trust no one and do it yourself,’ health care can no longer afford the each doing their own mentality of the past,” he said.

“I am a cardiologist and the complexity of my field is vast,” he added. “So we need to look across disciplines to find the best and most effective care for our patients. Finances may be driving health-care reform, but it is a great opportunity for us to change.”

A staff writer for The New Yorker since 1998, Gawande is a storyteller. He illustrated what he was saying with the story of a three-year old girl who was underwater for more than an hour after falling through ice. She had no pulse or respiration when she was pulled out, but was revived and eventually returned to full functioning because the hospital that treated her had put in place a process and a team that employed interventions expediently and methodically.

“We have enough science to do this, to bring someone back, but it required hundreds of people working together to follow numerous steps to get it right,” he said. “One person not washing their hands, one machine not ready, or a drug not anticipated could have changed the outcome.”

The event was cosponsored by the BU Health Sector Management Program and its alumni association, the BU BioBUsiness Organization, the Health Services Management Association, the BU Medicine and Business Association, and the Schools of Medicine and Public Health.


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