If you aren’t familiar with the concept of checklists to improve safety, they are a terrific tool. People often think, “I don’t need a checklist, I know what I’m doing!” Interestingly, professionals in other disciplines - notably aviation - have used checklists effectively for decades. The problem is, the job we are doing is so complex and complicated that our human minds can’t handle all of the information. The brain didn’t evolve for giving another animal a low level of a toxin to allow someone to put a sharp blade to it in order to fix it (i.e. anesthesia for surgery). It evolved to identify threats and food quickly. So we need other tools to help us. We need checklists!
Checklists help because they force us to stop and make sure we have done everything, even simple steps. Experts often do this process on their own. For example, before I anesthetize any patient, I mentally go through each step and make sure I have everything I need. During a CPR, I will routinely verbally describe what steps have been taken so far to make sure I haven’t missed anything. But I’m still relying on my (imperfect) memory and mental functioning. Checklists ensure that we do everything we’re supposed to. My first exposure to checklists was the book The Checklist Manifesto. In it, Atul Gawande describes his experience creating a surgery checklist in human medicine. Applying this simple checklist dramatically improved patient outcomes. I was immediately hooked and wanted to do something similar in veterinary medicine.
We devised a study to look at checklists in our practice. For 11.5 months, we kept a record of all anesthesia-related problems: wrong drug, wrong dose, incorrect route, closed popoff, esophageal intubation, etc. At the end, the team sat down to look at them and come up with a plan to reduce their incidence. We came up with four steps: someone always checks a machine after the initial person, someone always visually confirms intubation, arterial catheters are covered in a different-colored wrap, and the drug, dose, and route are always said aloud before giving a drug. The first two had checkboxes added to the anesthesia sheet to confirm they were done.
In the subsequent 12 month period, we had a reduction of adverse events of approximately 50%! That sold me on the value of checklists. Since then, I have carried similar protocols to other institutions and have seen them help.
Checklists work! Airplane pilots use them, astronauts use them, human surgeons use them. Anyone doing complex, complicated work should make use of checklists. Developing and implementing them can be a challenging process, and will be described in other blog posts.
Erik Hofmeister DVM Diplomate ACVAA & ECVAA MA MS
Professor of Veterinary Anesthesia