Live at HIMSS14: The Time is Now
When I was in nursing school, I worked as a scribe for an orthopaedic surgeon. Hospitals were powered by pen, paper and Selectric typewriters. Apple was still in a garage and Microsoft’s annual revenue was a mere $22,496. Every day I typed his schedule, and per his orders spent the next hour double-checking it against the OR schedule, the consent forms, office exam notes and X-Rays comparing every last detail. One day I asked him why.
Thus began my first abject lesson on clinical errors.
During his fellowship, he was on call when his orthopaedic attending was brought in – an attempted suicide. The surgeon had let his malpractice insurance lapse as he neared his retirement. Not long after, he performed a triple arthrodesis (fusing the bones solid) on the wrong ankle. This devastating mistake left the patient in a wheelchair.
Make your list, check it twice
Operating Rooms were early adopters of checklists. We learned from pilots and astronauts – who also have precious little “wiggle room” with which to risk human life. While the Institute of Medicine’s 1999 landmark piece, To Err is Human, ushered in an unprecedented focus on patient safety, we still struggle. The Joint Commission estimates wrong-site surgery occurs 40 times a week and notes that the number of reported cases nearly doubled in 2010 over 2004.
To err may be human, but, we’re a problem-solving, course-correcting species. The concept of using checklists may be simple, but it works. And, now technology presents us with an opportunity to take checklists to the next level, improving process performance, increasing accuracy and ensuring consistency.
The time to do so is now.
As HIMSS kicks off today, add visiting Hyland Software’s OnBase booth #2364 to your conference checklist. While there, be sure to pick up your free copy of Atul Gawande’s The Checklist Manifesto: How to Get Things Right.