The Last Checklist

flying cadeuciiEarlier this year, when my mother was briefly hospitalized, nobody gave her the wrong medication (her wristband was checked before each medicine was dispensed).  Nobody missed a high or low blood pressure (her vital signs were taken every few hours, like clockwork). She was usually assisted to the bathroom so she wouldn’t fall (a sensor on her bed triggered an alarm if she started to get up).

Thank goodness for hospital-based checklists, now ubiquitous in large part thanks to Atul Gawande’s bestseller The Checklist Manifesto, which have succeeded in knocking down the numbers of pressure sores, blood clots, falls, infections, and other errors and complications. As a doctor myself, I’ve heard many stories about close calls where checklists were crucial: just the other day, a colleague told me about a biopsy specimen that was almost logged in as the wrong patient; by following a simple checklist, what could have been a catastrophe was downgraded to a near-miss.

And yet during my mother’s hours in the emergency room, the staff seemed uninterested, overworked, and unavailable. We had no sense that any particular person knew what the others were doing. One doctor told us that she would definitely be admitted, while a nurse told us that discharge was imminent.

There’s more to creating a positive patient experience in the hospital than preventing medical errors. When a patient looks back on a hospitalization experience, she’s more likely to remember a plethora of positives – that nurses and doctors communicated with her kindly and regularly, that she felt cared for, that a ring on the call bell produced a person ready to help right away; than an absence of negatives – that she didn’t fall, didn’t develop a line infection, and wasn’t given the wrong medication. The items listed on the patient satisfaction surveys that are mailed after a hospitalization question whether staff members listened and provided information in a satisfactory way; they don’t ask patients to rate whether bad things didn’t happen.

Without a checkbox for ensuring a good patient experience, it’s often luck of the draw. In my mother’s case, nobody explained to us how the many people passing in and out of the room worked together on a team. Nobody provided much reassurance or caring. A few people asked if we had questions but didn’t return with answers.

Originally intended to have a supporting role, the checklist has, in many cases, ascended to unintentional stardom. But thanks to my sudden change in perspective from checklist-happy healthcare professional to family member of a hospitalized patient, I realized what I hadn’t really appreciated before: that checklists could easily become a crutch. If something wasn’t listed, it wasn’t important, or at least not as important as the items that were there. Checklists should supplement, not supplant, the dignity, caring, trust, and kindness that every patient needs.

At many medical schools, students learn communication skills by practicing with actors trained to portray patients, or by role-playing the patient themselves. And yet, after many years of teaching these sessions and practicing medicine, I’ve found that there is nothing like experiencing a hospitalization, either as patient or close family member, to truly appreciate the ineffability of the hospitalized patient’s experience.  Only by being hospitalized oneself, or spending hour and hours at the bedside of someone close to you, can you grasp that miserable combination of anxiety, frustration, boredom, discomfort, fear, and uncertainty that rolls through a hospitalization in seismic waves.

And yet there is a way around this, a way that does not require medical students to spend a night in a simulated hospital bed atop wet sheets, without enough blankets, with a faulty call bell, to grasp what additional “human experience” items should be on the checklist.

More than twenty years ago, when I was a medical student, I jotted down another surgeon’s suggestions. To us students, chief of surgery Dr. Frank Spencer was an intimidating, blunt-spoken, larger-than-life figure who not infrequently hollered at his residents. With patients, he was a different man, and he exhorted us again and again to follow a set of rules – a checklist, really, although he didn’t call it that. It was a step-by-step guide to acting humanely with patients, because, after all, the chaos of the hospital makes it so easy to forget:

o   Treat the patient like a family member, with dignity and respect.

o   Be gentle and honest.

o   Don’t rush.

o   Make them comfortable.

o   Acknowledge their fear.

o   Don’t sit behind a desk.

o   Encourage them to ask questions.

o   Grade yourself by how you feel when you leave the room. If you leave with a smile, give yourself an A.

To be sure, it may be distressing for patients to think that hospital staff need such reminders. But the whole point of checklists is to ensure that we don’t overlook the most obvious tasks, like checking temperatures and blood pressures or making sure we are in fact talking to (or taking a scalpel to) the right patient. Or treating a patient like a family member, with dignity and respect, and acknowledging their fear.

It’s been five years since the publication of Gawande’s book. Rather than resting on the laurels of checklist successes, I propose we acknowledge that a bad patient experience is a medical error, too. Let’s add these humane reminders to every hospital checklist. Stat.

Anna Resiman is an associate professor at the Yale School of Medicine and is a ” Public Voices fellow at the Op-Ed Project.”

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4 replies »

  1. In addition to the above text, some information provided are not properly explained to the patient. Especially the “why”.

  2. sometimes the minor mistakes could be the crucial mistakes

  3. Dear Dr. Reismann,

    I trust your mother is doing well. Like you, I had a similar mentor/example of your Dr. Spencer, the hard-nosed, but motivated and caring physician, who served as an example of how to take good care of folks. I think many of us in medicine have a similar experience, at least, I hope that we all do.

    However, I found it interesting that you mentioned that your Dr. Spencer didn’t actually use a “checklist,” but somehow he managed to provide excellent care to his patients. Was he really not as good a physician as he appeared? Did he really risk catastrophe on a daily basis, since he didn’t pull out his checklist and run down it with every patient encounter? Do we really need a “checklist” to remind us to treat our patients “humanely? I hope that if it ever comes to that, I will just throw in the towel and become a plaintiff lawyer.

    As an ER physician of many years, I can readily appreciate that the ED appears (and sometimes is) to be a disorganized, chaotic, frightening place. The deck of an aircraft carrier during air operations might be a similar, if not slightly more dramatic, comparison. Patients are stressed, families are stressed, and staff are stressed. There is little margin for error. Unlike every other component in a hospital, the ED has zero control over how many patients it is required to care for at any given time.

    My point being, I am not opposed to checklists. I just want people to understand that adding extra steps takes time and effort, and that time and effort exponentially expands with the number of people seen in the ED. Right now we are at something around 130 million ED visits in the U.S., and we just added the complexity of ICD-10, and also some ridiculous requirements called “PQRS” that require us, in the ER, mind you, to document the patient’s last HgbA1c, or that someone with a broken leg is counseled about their BP being higher than 120/80, or whether patients with chronic afib are prescribed anticoagulants (by the ED physician, no less!).

    PPACA promised us that ER visits would decrease, but we knew that was a whopper of a lie. Give more people Medicaid to use the ER for free, and ER visits will continue to go up. As your contractor probably told you, “You can have it fast or you can have it cheap, just not both.” Or, put another way, we used to have a saying when I was a just a redneck working on race cars: “speed costs money, so just tell me how fast you want to go?”

    In other words, we can have a zero error rate for everything in emergency care. Just don’t ask me to see, evaluate, and treat 40 patients per shift, when my ED is the literal dumping ground for drug seekers, doctors who turn off their phones at 4:30 pm, the entire panoply of social ills (including HIV care, GSW’s, rapes, STD’s, homelessness, etc.) and BTW, doesn’t anyone actually speak English anymore? We could practice Dr. Spencer’s care when the ER was actually a place where you went when you had an actual emergency, instead of where you get your free pregnancy test, or because your dog ate your Oxycontin prescription, or because your hospice nurse told you to come get your cough checked out because you might need a Z-pak.

    I can understand your frustration. I promise you, the ED staff is easily as frustrated, confused, and in the dark as you felt that day with your mom in the ER. Help us help you.