Earlier 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.