Checklists: From the Cockpit to the Radiology Department

OPINION

Checklists: From the Cockpit to the Radiology Department David C. Levin, MD The recent interest in using checklists to improve the quality of medical care derives, in part, from their success in aviation. Earlier in life, I had experience with checklists, and here is one vivid memory of that experience. It was a clear day over Phalsbourg Air Force Base in eastern France, many years ago. At the time, before deciding to go to medical school, I was a fighter pilot in the US Air Force there, flying F-86 Sabrejets with the 513th Fighter Interceptor Squadron. My practice mission was completed, and I flew my F-86 into the traffic pattern for a standard racetrackshaped VFR (visual flight rules) jet fighter approach. Like all my fellow pilots, I followed a mental checklist for landing. I knew the drill by heart and can still remember it clearly all these years later: Enter the pattern at 1,500-feet altitude and an airspeed of 250 knots, lined up with the landing runway. Fly one-third of the way down the runway, then roll into the pitchout, a sharp 180° turn to the downwind leg while maintaining altitude. Pull about 4 Gs in that turn, and while in it, cut the throttle to idle RPM and extend the speed brakes (doors that came out the side of the fuselage to create drag and slow you down quickly in the air). Roll out on downwind. Push the landing gear handle down to lower the gear. Push the flap handle down to lower the flaps (flaps provide more lift to the wings at low airspeed). Adjust the trim tabs. Check the indicator to make sure all 3 landing gear are down and locked. Advance the throttle to maintain an airspeed of 175 knots. Look back over your shoulder to see where the runway is and make sure you had passed beyond the landing 388

end of it. Execute another 180° turn, this time a descending turn, to line up with the runway on final approach. Adjust the throttle to maintain 150 knots while descending on final, then flare out, throttle back to idle, and touch down. It was a mental-only checklist because things happened too fast to refer to a written list (the whole process took less than a minute). At that particular time, I was an experienced pilot and had flown this traffic pattern perhaps 250 times in fighter aircraft. It should have been a completely routine approach and landing. But as I began the second, descending 180° turn to final approach and let my airspeed slow to 150 knots, I noticed that I was losing altitude quicker than expected. So I pulled the nose up and added power to get more lift. But I was still losing altitude too fast. I pulled the nose up some more and added more power. A quick check of my engine instruments showed that the engine was operating normally. Still the toorapid descent continued. So, following my instincts, I pulled the nose up still more and added still more power. By this time, I was low to the ground and near the end of final approach with my airspeed around 180 knots (vs the 150 knots we normally flew on final), as a result of having added so much more power. In trying to get more lift and slow the descent, I had the aircraft’s nose tilted up so high I couldn’t see over it to the runway ahead. Instead, I had to look out the sides of the canopy to get visual reference to the ground. When I saw the end of the runway flash by, I pulled the throttle back to idle and let the aircraft settle on to the runway, probably going a good 40 knots faster

than I should have been. After touching down, the first thing one did was to retract the flaps, to reduce the lift on the wings and provide more traction for the brakes. I reached over to pull up the flap lever and— damnation—they were already up! I had neglected to ever put them down! I had to literally stand on the brakes to get my aircraft stopped, and I barely managed to do so before reaching the far end of the runway. The F-86 had a drag chute (just like the space shuttles), which we rarely used, but I didn’t want to deploy it because then I would have had to explain to my squadron operations officer why I had done so. Needless to say, I wasn’t anxious to confess my careless blunder to him or anyone else. The F-86 clearly didn’t like to fly at low speed without the flaps down. My mental checklist had failed me, but only because I inadvertently omitted a crucial step. I never did figure out what distracted me that day, but I do know I was lucky not to have killed myself. THE USE OF CHECKLISTS BY PILOTS

Checklists were, and still are, a very important part of a pilot’s routine. Each of us had a small metal clipboard that we strapped to our thighs when we climbed into the cockpit. On it, we clipped various navigation and approach charts, but the thing that was right on top was the F-86 pilot’s checklist. I and my colleagues used that checklist assiduously every time we prepared to start the engine. The cockpit was small and cramped and filled with a myriad of dials, gauges, switches, levers, handles, pins, buttons, and circuit breakers. There were about 40 of these things that had to be set properly or checked

© 2012 American College of Radiology 0091-2182/12/$36.00 ● DOI 10.1016/j.jacr.2011.12.022

Opinion 389

before engine start. Then the ignition sequence involved several steps that had to be done correctly. After the engine was running, there was another series of checks and settings that had to be accomplished before takeoff. All this was on that checklist. After takeoff, it behooved one to flip the checklist to the pages for in-flight emergencies and keep it there in case of need. There were 2 main reasons people like me used those checklists. One was that we were entrusted with expensive government property and were responsible for taking care of it. But the second and far more important reason was that our own lives depended on it. A single small lapse of concentration, as in the episode recounted above, could potentially kill you. There’s nothing like that kind of threat to focus your mind very clearly on following the rules— or the checklist. Checklists have worked for pilots for 75 years, and recently, physicians like Peter Pronovost and Atul Gawande have shown that they work in medicine also. As in aviation, many medical procedures involve a series of tasks that must be done correctly and in sequence. Failure to perform any one of them can result in serious harm to the patient. The use of checklists by physicians and nurses can minimize the human errors that are almost inevitable in caring for patients. This has been proven in intensive care medicine, surgery, and anesthesia, and I believe the time has come for radiologists to consider their use as well. THE HISTORY OF MEDICAL CHECKLISTS

In 2004, Pronovost et al [1] reported on an experiment performed in intensive care units (ICUs) at the Johns Hopkins Hospital. They introduced a simple checklist to be followed by ICU teams in an attempt to reduce bloodstream infections related to

central venous catheter insertions. Before any central line insertion, the checklist called for the ICU teams to (1) wash their hands with soap; (2) sterilize the skin insertion site with chlorhexidine; (3) cover the patient with sterile drapes; (4) wear a cap, mask, and sterile gown and sterile gloves; and (5) cover the catheter and insertion site with a sterile dressing. Nurses were empowered to stop the procedure if these guidelines were not being followed. The checklist was so simple as to seem superfluous, yet the physicians were initially found to be complying with the guidelines only 62% of the time. The implementation of the checklist led to astonishing results. The rate of catheter-related bloodstream infections dropped from 11.3 per 1,000 catheter-days to zero. Two years later, Pronovost et al [2] published a study performed at 103 ICUs in Michigan in which a similar checklist was introduced. The mean rate of catheter-related bloodstream infections dropped from 7.7 per 1,000 catheter-days before to 1.4 after the intervention. Similar beneficial effects have been achieved in operating rooms. In 2009, Gawande and his team described the results of the introduction of a 19-item surgical safety checklist in 8 hospitals around the world as part of the World Health Organization’s Safe Surgery Saves Lives program [3]. Among nearly 8,000 patients undergoing noncardiac surgery, the death rate dropped from 1.5% before the use of the checklist was instituted to 0.8% afterward. Complications during the inpatient surgical hospitalization dropped from 11.0% to 7.0%. Shortly thereafter, a similar study was reported on a subset of these patients whose operations were considered urgent [4]. The death rate dropped from 3.7% to 1.4% after introduction of the checklist, while the complication rate dropped from 18.4%

to 11.7%. Similar favorable effects of checklist use were reported by de Vries et al [5] and Ziewacz et al [6]. Greater safety in anesthesia has also resulted from the use of checklists. In a recent review, Staender and Mahajan [7] summarized the dramatic progress in anesthesia safety over the past 3 decades. Before 1980, anesthesia-related mortality was approximately 1 per 5,000. Currently, it is calculated to be between 0.4 and 0.82 per 100,000. One important reason for the improvement has been the introduction of checklists. THE IMPLICATIONS FOR RADIOLOGISTS

Atul Gawande is a surgeon at the Brigham and Women’s Hospital and also an outstanding writer. As a result of both an article in The New Yorker magazine [8] and a popular book by him [9], the use of checklists as a patient safety measure has been widely publicized. Depending on how one looks at it, this could create an opportunity, or perhaps an imperative, for radiology. There is much talk these days among radiologists about the need for improved patient safety and quality. The ACR has an entire commission dedicated to this very goal. I believe the time has come for radiologists to seriously consider instituting the use of checklists for many of our procedures, just as the intensivists, surgeons, and anesthesiologists have done. According to a recent study by Reddy et al [10], there is a clear need for this. They surveyed members of the Society of Interventional Radiology about their infection control policies during central venous catheter placements. Among 1,061 respondents, only 50% wore caps, 56% wore gowns, 42% wore masks, 54% fully covered the patient with sterile drapes, and 19% reported routine hand washing between glove changes. Interventional radiologists place many thousands of central lines each year, and these data indicate that there is ample room for improve-

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ment. A commentary by Zhang and Burbridge [11] reminded us that radiology departments are areas of high patient traffic and thus can be a major source of infection transmission. They listed a number of precautions that should be taken, many of which could be adapted to a checklist. Checklists could be appropriate for many interventional procedures performed by radiologists, not just central line placements. The World Health Organization has actually developed a checklist specifically for radiologic interventions [12], adapted from its surgical safety checklist alluded to above. They could also be used in the treatment of serious contrast reactions. Although these are infrequent, too many radiologists in outpatient facilities rely on calling 911 when they occur. By the time emergency responders get there, it may be too late. We are physicians, after all, and we should be able to handle these emergencies ourselves; checklists would help. They could perhaps even be used in the interpretation of some noninvasive imaging studies to be sure nothing is overlooked. So checklists would help radiologists provide better care for our patients and establish us as leaders and innovators in quality and safety. For these reasons, we should think seriously about implementing them as part of our daily practice. But lest anyone think this will be simple to accomplish, note that there is a crucial reason why checklists will not work as well in hospitals as they do in aviation. It has to do with who gets hurt if a mistake is made: If a pilot slips up, he or she might be killed. By comparison, if a doctor or nurse slips up, it’s only someone else who might be killed. So maybe the same sense of urgency about reading a checklist isn’t there. Perhaps the doctor or nurse didn’t sleep well the

night before or got distracted by some personal issues. Or perhaps that individual just has a somewhat indifferent attitude toward patient care and doesn’t want to bother; after all, it isn’t their own life or health that’s being put at risk. Whatever the reason, if that focus is missing and someone isn’t willing to read the checklist aloud and enforce its guidelines, key steps in the process might get omitted, and that could lead to serious consequences. You can bet a lot fewer errors would be made by us medical professionals if our own lives were on the line, rather than someone else’s. Another reason checklists may not work as well in hospitals as in aviation is that human beings are much more complex and unpredictable than airplanes, which after all are just machines. Checklists will not solve all the challenges inherent in the attempt to improve patient safety, but they will certainly mitigate a number of such challenges. They have proven to be of great value, and Pronovost and Gawande deserve much credit for popularizing their use in medicine. But along with those checklists must come a sense of true urgency and concern for the welfare of the patient. We must use those checklists as carefully as if our own lives were at stake. Checklists will only work if they are used in a formal manner with a real commitment to adhere to them. It isn’t enough to just memorize them and hope you’ll be able to recall all the steps. If I had had a copilot reading a checklist aloud to me and following my every move, those flaps would have gotten lowered. But the F-86 was a single-seat aircraft, and no one else was around. In the hospital, there are almost always other personnel around. One of them needs to be reading that checklist aloud and making sure every step in the process is carried out in se-

quence. Someone’s life may depend on it. REFERENCES 1. Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004;32:2014-20. 2. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725-32. 3. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9. 4. Weiser TG, Haynes AB, Dziekan G, Berry WR, Lipsitz SR, Gawande AA. Effect of a 19-item surgical safety checklist during urgent operations in a global population. Ann Surg 2010;251:976-80. 5. de Vries EN, Prins HA, Crolla RMPH, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med 2010;363:1928-37. 6. Ziewacz JE, Arriaga AF, Bader AM, et al. Crisis checklists for the operating room: development and pilot testing. J Am Coll Surg 2011;213:212-9. 7. Staender SEA, Mahajan RP. Anesthesia and patient safety: have we reached our limits? Curr Opin Anesthesiol 2011;24:349-53. 8. Gawande A. The checklist. The New Yorker. Available at: http://www.newyorker.com/repor ting/2007/12/10/071210fa_fact_gawande?prin table⫽true. Accessed November 14, 2011. 9. Gawande A. The checklist manifesto. New York: Picador; 2009. 10. Reddy P, Liebovitz D, Chrisman H, Nemcek AA Jr, Noskin GA. Infection control practices among interventional radiologists: results of an online survey. J Vasc Interv Radiol 2009;20:1070-4. 11. Zhang E, Burbridge B. Methicillin-resistant staphylococcus aureus: implications for the radiology department. AJR Am J Roentgenol 2011;197:1155-9. 12. World Health Organization. WHO surgical safety checklist for radiological interventions only. Available at: http://www.nrls.npsa. nhs.uk/resources/?entryid45⫽73612. Acces sed November 21, 2011.

David C. Levin, MD, Thomas Jefferson University Hospital, Department of Radiology, Main 1090, Philadelphia, PA 19107; e-mail: [email protected].