This post from guest blogger Dave Pantzer discusses Atul Gawande’s 2009 book The Checklist Manifesto: How to Get Things Right, and suggests that the legal profession take seriously the challenges and opportunities set forth in the book.
Anthony DeFilippo almost died in intensive care after one of the lines a doctor had inserted into his blood stream apparently became infected. The data on line infections are grim: “ICUs put five million lines into patients each year, and national statistics show that after ten days 4 percent of those lines become infected. Line infections occur in eighty thousand people a year in the United States and are fatal between 5 and 28 percent of the time.” There are countless other risks as well, but just eliminating line infections would make a huge difference to the safety of intensive care.
One doctor at Johns Hopkins, Peter Pronovost, set out to eliminate that one source of risk, using the following five-step checklist: Doctors must:
- Wash their hands with soap;
- Clean the patient’s skin with antiseptic;
- Put sterile drapes over the entire patient;
- Wear a mask, hat, sterile gown, and gloves; and
- Put a sterile dressing over the insertion site once the line is in.
It sounded simple, even silly, but they found that in one third of cases, at least one of these obvious steps was skipped. To ensure compliance with the checklist, the hospital administration empowered nurses to stop doctors if they saw a missed step. Nurses were also directed to check with doctors daily about which patient lines could be removed.
The results? After a year of trying the plan, the data was almost unbelievable: “the ten-day line-infection rate went from 11 percent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths and saved two million dollars in costs.”
This startling account appears early in the pages of Dr. Atul Gawande’s thought-provoking book The Checklist Manifesto: How to Get Things Right. This book, written by a surgeon, is not just about the medical profession. Dr. Gawande investigates how different kinds of checklists can prevent errors in disciplines as varied as investing, building skyscrapers, and flying airplanes.
Of course, not all tasks can be performed by a single expert with a five-step checklist. Constructing a new building, for instance, involves the interaction of specialists and experts from sixteen different trades. Each trade may have its own checklists to ensure their individual responsibilities are met, but what happens when the experts from the different trades have different ideas? How are decisions made in the face of major, unexpected developments? Can checklists help prevent errors in situations of such complexity?
For this situation, the construction industry uses a different type of checklist – a communications checklist: “the way project managers dealt with the unexpected and the uncertain was by making sure the experts spoke to one another – on X date regarding Y process. The experts could make their individual judgments, but they had to do so as part of a team that took one another’s concerns into account, discussed unplanned developments, and agreed on the way forward.”
The book is about very simple processes (task verification checklists and communication checklists) and how they can, and have, incredibly reduced error rates in high-impact disciplines like surgery, flying airplanes, building high-rises, and even investing (despite the fact that many of these tend to be high-intuition, expert-driven, even lone-ranger types of professions.)
The Checklist Manifesto concludes with a challenge to, among others, the legal profession – a challenge to search out the patterns of mistakes that plague our profession and to identify and develop solutions. And the good news is that many of those solutions are cheaper, simpler, and more elegant than we might think.
“We are all plagued by failures – by missed subtleties, overlooked knowledge, and outright errors. For the most part we have imagined that little can be done beyond working harder and harder to catch the problems and clean up after them. We are not in the habit of thinking the way the army pilots did as they looked upon their shiny new Model 299 bomber – a machine so complex no one was sure human beings could fly it. They too could have decided just to ‘try harder’ or to dismiss a crash as the failings of a ‘weak’ pilot. Instead they chose to accept their fallibilities. The recognized the simplicity and power of using a checklist.”
Which balls do we see being repeatedly dropped in the legal profession?
For the bench: Which entirely preventable procedural errors cause otherwise good decisions to be overturned on appeal? What players in the system need to be empowered, like the nurses at Johns Hopkins, to throw a flag and stop the play?
For the bar: What steps are lawyers missing, not because they are uninformed or unprofessional, but just because the situation is unusual, or because too many voices are clamoring for their attention?
For all the players in any one of a thousand situations that affect the lives and livelihoods of litigants: Where do we need to stop and make sure concerns are raised and voices heard? And what systems can we formalize to make sure we all learn about the solution to a problem that one of us just solved?
These aren’t rhetorical questions. I don’t know the answers. I suspect that if we regularly pause to discuss and assess the patterns of our mistakes (and our successes) we will find that many problems can be solved, and much pain can be avoided, with this free technology: the checklist.
Dave Pantzer manages the Maryland People’s Law Library (www.peoples-law.org) for the Maryland State Law Library. Dave teaches undergraduate law at Towson University and gives seminars on clear writing. He can be reached at email@example.com.
Nice job Dave. I am a big fan of Dr. Gawande. In many ways, he is not unlike Bruce Lee who taught about the power of simplicity (and single handedly revolutionized the world of martial arts – all by the age of 32).
Our legal profession is so reactive that it seems almost impossible to be able to follow a plan. Thanks for causing me to think about Dr. Gawande’s work again and challenge me to improve my practice.
Richard, A remarkable additional fact about Peter Pronovost is the degree to which he has managed to get his efforts disseminated to doctors in all 50 states. This success, a critical addition to the proof of principle cited, is one of the reasons for hoping that docs will be a valuable element in health care reform.
If there is a serious legal checklist effort it will need a similar success in creating committment by lawyers in the field to make it happen. Jim