Checklists and Other Medical Error Reforms

225px-Peter_Pronovost.jpgThis month’s Reader’s Digest features an article entitled “Doctors Confess Their Fatal Mistakes,” which contains the stories of five haunting medical errors, only one of which resulted in any legal consequences for the practitioner (a pharmacist).
From my perspective, the most interesting story involved Dr. Peter Pronovost, an outstanding Johns Hopkins physician and MacArthur “genius grant” recipient for his work on developing checklists for doctors to follow. Dr. Provonost’s account of a medical error that he committed as a medical resident highlights two important medical reforms that could easily be undertaken to reduce the incidence of medical malpractice: implementing checklists and making sure residents are not overtired.
Dr. Pronovost, one of the leading clinical figures of his generation, helped develop medical checklists that, in a worldwide pilot study, reduced surgical deaths by 47 percent and serious complications by 36 percent. As a young resident doing specialty training in critical care, Dr. Pronovost (fatigued by not having slept within the past 24 hours) made the hasty decision to remove a patient’s breathing tube and transfer him out of ICU.
The patient’s breathing sped up and Dr. Pronovost had difficulties reintubating the patient. While Dr. Pronovost attempted to reintubate the patient, the patient was without oxygen for three to five minutes, a time period that can result in brain damage. Fortunately, Dr. Pronovost’s patient did not suffer any brain damage and did not sue for medical malpractice.
Dr. Pronovost believes that before he pulled his patient’s breathing tube he should have had to complete a medical checklist that would have revealed to him that the particular patient that he was dealing with would be difficult to reintubate. Provonost notes that NASCAR crews and airline pilots use checklists to save lives and so should doctors. Why is American medicine so resistant to checklists? Dr. Provonost thinks it has to do with the “myth that doctors are perfect.”
Dr. Pronovost’s story also highlights the need to make sure that medical residents receive adequate sleep and supervision. Dr. Pronovost made the decision to remove his patient’s breathing tube while working a 36-hour shift where he had been awake for 24 hours. Even after the 2003 reforms in working hours for residents, such working hours are still common.
In a way, the need for widespread use of checklists and the need for reduced resident hours go hand-in-hand. The medical checklist model is borrowed from the development of the aviation industry where, as planes got increasingly complicated and difficult to fly, airlines faced two choices: 1.) either train pilots for years on end (i.e., develop a more and more expert core of pilots, analogous to doctors) or 2.) replace individual autonomy of pilots with checklists. Residents are overworked because medicine has decided to give us a corps of highly trained professionals, whose autonomy is almost unbounded, and that training involves thousands of hours spent as a sleep-deprived resident.

This blog is maintained by the Boston medical malpractice lawyers at The Law Office of Alan H. Crede. It does not offer legal advice relative to any medical malpractice injuries that you may have suffered.