Ticking the right boxes

Abstract

Does the Guinness Book of Records, I wonder, have an entry for the doctor who has saved most lives? Immediate candidates that spring to mind are Ignaz Semmelweiss, Alexander Fleming, and Richard Doll. Living candidates are harder, but one who, I predict, may soon be among them is US surgeon, Atul Gawande. As well as wielding his scalpel at Boston's Brigham and Women's Hospital and the Dana Farber Cancer Institute and being a staff writer for The New Yorker, he fronts WHO's drive to implement the surgical safety checklist—19 items to be run through, in the same way that pilots check the cockpit, before an operation begins. Last month Gawande gave the James Reason Inaugural Annual Lecture, at London's Royal Society of Medicine. He discussed the latest findings of the Safe Surgery Saves Lives Study Group, which show that use of this checklist cuts deaths by almost half and complications by more than a third (NEJM 2009; 360: 491–99). Given that 234 million operations are done globally each year that translates to millions of lives saved (Lancet 2008; 372: 139–44). But how to get surgeons—individuals not given to self-doubt—to do it? Early experience has shown around 20% of surgeons were sceptical about its value. Yet when asked if they would want the checklist used when they were a patient, 93% replied yes. As Director of WHO's Global Patient Safety Challenge, Safe Surgery Saves Lives, Gawande says two things are necessary to secure change: measure performance and publish the results. When sceptical surgeons are shown that wound infection rates are too high in their patients, they will start to use the checklist to remind them to give preventive antibiotics before the operation. Peer pressure is the great driver. The beauty of the checklist is that it is simple, cheap to implement, and more effective than a whole bunch of miracle cures. Some really big advances in medicine are likely to come not from technological breakthroughs and new ways of working but from doing what we have always done, but doing it “better” (the title of Gawande's 2007 bestseller). That requires vigilance, diligence, and ingenuity, which the checklist can assist. Having been promoted in intensive care by Peter Pronovost, the checklist is already here for surgery and will shortly be extended to maternity care, cardiac care, and other areas of medicine. It may turn out to be the greatest clinical innovation in the past 30 years.