In the airline industry they have checklists. In Japan, train operators point and vocalize. In my volunteer fire department, we've adopted a "two sets of eyes" policy on all technical rope rigging before declaring it ready.
I know humans are fallable, but I feel like there are some basic, workplace culture driven techniques that could substantially help here.
There's plenty of checklists in the medical field as well. Specially during triage of all kinds.
The main issue is that in most jobs people will say new checklists won't work for /them/ because they understand it better than the checklist, or because the checklist will slow them down. Think about your own work and you'll find reasons why checklists don't make sense, I bet.
I once went in for a surgery on a foot and when rolled into the room the doctor asked me if I had any last minute questions and I asked only 'which foot are you operating on'. After a few seconds of confusion he gave a decisive right answer and even told me 'here, if it makes you feel better I'll sharpie your leg'. And it did make me feel better - there's so much that can easily go wrong by a minor mistake from them which will be life changing for you.
Alarming that that was a last minute question and an "if it makes you feel better" offer, honestly, even if it obviously went fine. On the day of my surgery I was constantly being asked what it was and on which side, by nurses, by the anaesthetist, the surgeon came and saw me on the ward beforehand and verbally confirmed it, palpated the correct area, and drew on me, and then on the bed before they put me under I was asked to lift the blanket and show there was an arrow and confirm that it was correct in front of basically the entire team. It would've been literally impossible to doubt that they knew what they were supposed to do.
Usually they are supposed to pro-actively ask you that I think. When I had a fracture in my upper arm everyone would ask me which arm it was. The patient is a good independent backup for easy flip/flop errors.
> in most jobs people will say new checklists won't work for /them/ because they understand it better than the checklist, or because the checklist will slow them down.
I fought this fight for a long time as an executive in charge of ops with a team that had a critical enterprise product and refused to use source control.
Yes, and The Checklist Manifesto (which is a fantastic book) was published in 2009; yet it seems little progress has been made since.
It's not just checklists, though, it's also basic CRM. If the lead surgeon is God, and you're a nurse, you don't speak up -- you probably don't even believe your own senses when they tell you something's wrong.
A fundamental change is sorely needed -- not sure what will make it happen.
The Checklist Manifesto is good, but it was a little confused over what checklists are.
Almost all of the examples discussed are actually checklists: before you do something, you go over the checklist and make sure whatever it says to do has been covered.
But the example of soap distribution in India isn't like that at all. The notional "checklist" was a list of several circumstances in which you should use soap:
1. Before preparing food.
2. After using the bathroom.
3. After wiping an infant.
4. [There were others; I don't remember them.]
This is a good and valuable set of information to publicize. But it isn't a checklist. Interpreted as a checklist, you would need to check it before and after every action you ever take. That is obviously not something people can do. You use this list by doing the work of modifying your relevant habits to include "wash with soap" at an appropriate stage, which is exactly the kind of approach to doing things that the rest of the book is telling you doesn't work.
It's definitely widely used in Germany, where I work. I don't know how common it is in the US, though.
I often think about what makes medicine so different from aviation and your other examples, culture-wise. It's not like there's no safety culture at all in medicine, but clearly these kinds of structures are deployed to a much lower extent.
One major reason might be the far larger diversity of possible situations in medicine. It's possible to make a checklist for surgical safety because every surgery is similar, same to how every plane flight is similar. But if I think about, for example, harm due to adverse effects from medications, or missed abnormal values in blood tests, it feels very difficult to create a checklist to prevent those that would be specific enough to be useful, but also general enough to capture all important situations these might arise in.
In this sense, I think certain “low-hanging fruit” of safety culture improvements have already been captured in medicine. Apart from surgical safety, I can think of check lists for chemotherapy administration, for blood transfusions, for management of a severe allergic reaction, and other specific individual things. Pointing and vocalizing is also done in surgery, albeit in a less formal way. “Two sets of eyes” policies exist in e.g. pathology for more certainty in diagnosis of cancer.
Nevertheless there is clearly room to improve, as evidenced by the continuing occurrence of “never events” such as retained foreign bodies in surgery. There are certainly economic factors at play here as well: unlike in the free market, in the medical system there is often very little economic incentive for quality, and the same principle I mentioned before — of the immense diversity of possible situations — makes top-down regulation very tricky.
Maybe part of it is also that the potential harm from a retained foreign body is much lower than the potential harm from a plane crash. And maybe medical care is so much more common than plane flights that by base rate alone, mistakes in the former will be much more common. Yet I still think there is much that can be done, and I am unsure what exactly is preventing that from happening.
> One major reason might be the far larger diversity of possible situations in medicine
Yes but the major is the number of deaths. An incompetent surgeon can kill at most one person at a time. Besides, variance in surgery is much higher than in aviation.
not to be pedantic, but the examples you're describing are _process_, not _culture_.
Examples of culture would be: do nurses feel comfortable speaking up / questioning the lead surgeon? do surgeons feel like they can voice when they're overworked without fear of being perceived as a failure?
As a comparison in the UK there is robust mandatory reporting on "Retained foreign object post procedure" which is a so-called "Never Event" in the most recent publication (April 2024 to September 2024) this occurred 60 times[1] in the NHS in England. For a denominator there are approximately 21 million operation performed in a year by NHS England[2]. So roughly 0.002% of cases have an unintended retained object or roughly 1 in 50,000.
For further reading the Health Services Safety Investigations Body in the UK (like the NTSB but for healthcare incidents is the best worst analogy) looked at retained foreign objects and published in 2024: https://www.hssib.org.uk/patient-safety-investigations/retai...
My mother had rags left in her during a surgery that ended up fucking up the course of her life forever and leaving her permanently disabled. The rags didn’t cause the primary problem, but were just a part of their shoddiness.
Of course it’s not every surgeon, but there are some butchers that out happens more with. It ended up being a repeat problem for my mother’s surgeon.
When my wife had some minor surgery (not fully anesthetized), there was a nurse present who counted all of the sponges, etc. that were used, then made sure there were that many on the tray at the end. They didn't match up, and it turned out that the surgeon had dropped one off of the table.
The article mentions that counting is standard procedure, so hopefully this is how it works everywhere. It definitely seems like having someone who isn't the surgeon doing the counting would be the way to go. The surgeon is already very focused and it's easier to say "I'm sure I didn't leave anything" when someone else isn't telling you otherwise.
Doctor here (non-USA). This is standard procedure and has been standard ever since I was a medical student, almost 20 years ago. The "running nurse" is in charge of maintaining a count and making sure that nothing is left inside the patient.
Swabs and towels tend to come in pre-prepared packs, so the nurses have another source of truth. Any mismatch between the preprepared count, running count during the operation, and actual swabs/towels laid out at the end is a serious cause for concern. You will not close up a patient if there is a mismatch.
Yeah, back in the late 90s I was able to observe a number of surgeries (different story) and I remember the counting being almost fanatical. They had what looked like a shoe holder that hung on a door for putting each rag that was used. Every instrument that was used was accounted for during and after. The surgeon was definitely not the counter.
My wife is an OR nurse and jokes her primary job responsibility is counting. Frequently when surgery is going long it's because someone threw out or dropped something that was supposed to be accounted for and they won't close the patient up until that's found, even if that means sorting through the garbage.
Fifteen or 20 years ago I remember seeing something about using bar codes to "check out" and "check in" all the tools so nothing was unaccounted for. Unclear if that system's been widely adopted, though.
They do something like that in aircraft manufacturing - every tool has a dedicated spot in the toolbox and a job can't be signed off unless all the tools are back in the toolbox. Bolts, nuts, and other parts/debris are a different story though... there's horror stories from that as well, especially recently from one of Boeing's facilities implicated in the string of manufacturing and maintenance related incidents Boeing had in the last couple years.
"Dottore, still counting ? Hurry up, there are 10 more patients avaiting surgery today. The profit of the company and your bonus are in danger. Hurry up"
You could frame it a different way; what level of risk would be acceptable vs. the reduction in cost/time/use of resources. If you're 10% faster for 0.1% risk, is that a better outcome for society?
You could, but the willingness to frame it that way at a local decision-making level causes problems for global optimization. It's perfectly fine for a surgeon to triage patients and actions. It's much less fine for a hospital administrator to decide they can get away with less staff because the increase in risk isn't _that_ high (maybe only a couple extra deaths per year). Perhaps it's fine to make that tradeoff, but the blatant conflict of interest and history of people doing worse things for less money suggests it should at least have oversight.
We are all already part of this conversation, all the time, because resources are finite
The flip side is "sorry, we didn't have enough surgeons available right now so we have to triage you", or, "sorry you can't afford the bill"
I'm sure in this particular situation the numbers benefit "don't leave surgery debris in the patient" but the more general point remains, there is some set of numbers (likely implausible) where it would flip the other way
Hate it all you want but these decisions of how much percentage death is legally allowed happens whether you like it or not. Otherwise we'd have no cars on the road, no planes in the sky, no boats, no swimming, no cycling, etc
10% faster could easily be more than 0.1% better for society. Less risk for infection or other problems, more people can be seen etc. Its entirely about weighing pros and cons and you are being ignorant by assuming otherwise.
Not all surgeons are alike, just as in any profession: some make many errors and some make few. But doctors unions fight tooth and nail to prevent the publication of information that would allow patients to make informed decisions about their surgical provider, which removes the financial incentive for surgeons to do better and prevents bad surgeons from being weeeded out of the market.
unlucky for you we have a control group with Canada's public health system where surgeons still leave things inside people and no efficient market to "weed them out" so I don't think this is correct
In my previous life I once taught a theatre production class in which one of my students was a surgical nurse. She was fascinated by the prop table. For those of you who don't know, standard procedure - at least with every Stage Manager with whom I ever worked - for a prop table is to draw an outline around every item, which in one step defines a place for everything and allows one-glance inventory assessment. Well, this nurse said she hadn't seen or thought of that approach, which would speed up and make more reliable the "count in and count out every surgical instrument" part of her role, and she vowed on the spot to implement it at work.
It's the only time in my theatre career I might have maybe indirectly saved a life.
That’s a brilliant idea that’s exactly what it should be! Wow, how about we found a medical device company that’s like a table that will let you know when the device it needs is not back on the table? Seriously I always wanna get into hardware. cris@dosaygo.com
Though honestly, I’m sure you saved many other lives directly or not by theater that speaks to people, that they can identify with.
I do the same for my wall of tools, and it's also helped my partner remember to put them back after she borrows one. (But it makes me grumpy when one gets lost and I can't find a replacement that's the same size and shape).
This sounds like the perfect application of image processing and machine learning. A computer with a camera attached could monitor the whole operation and warn the surgeon if it detects an object going in but not out.
At least it would be more useful than the system they use for self checkouts at my local supermarket. "Did you forget to scan something in your trolley?" Yes, it's my child.
maybe? If you've every seen a non-trivial surgery there are lots of people, action and "things inside you". I'm not convinced we should or even can optimize for camera field of view and ML - especially when this feels more like an accounting problem than an image processing problem.
At least in America, surgeons are part of an entitled medical elite, and there is tragically little interest in holding them to account. Let alone forcing them to do better.
In the airline industry they have checklists. In Japan, train operators point and vocalize. In my volunteer fire department, we've adopted a "two sets of eyes" policy on all technical rope rigging before declaring it ready.
I know humans are fallable, but I feel like there are some basic, workplace culture driven techniques that could substantially help here.
There's plenty of checklists in the medical field as well. Specially during triage of all kinds.
The main issue is that in most jobs people will say new checklists won't work for /them/ because they understand it better than the checklist, or because the checklist will slow them down. Think about your own work and you'll find reasons why checklists don't make sense, I bet.
I once went in for a surgery on a foot and when rolled into the room the doctor asked me if I had any last minute questions and I asked only 'which foot are you operating on'. After a few seconds of confusion he gave a decisive right answer and even told me 'here, if it makes you feel better I'll sharpie your leg'. And it did make me feel better - there's so much that can easily go wrong by a minor mistake from them which will be life changing for you.
Alarming that that was a last minute question and an "if it makes you feel better" offer, honestly, even if it obviously went fine. On the day of my surgery I was constantly being asked what it was and on which side, by nurses, by the anaesthetist, the surgeon came and saw me on the ward beforehand and verbally confirmed it, palpated the correct area, and drew on me, and then on the bed before they put me under I was asked to lift the blanket and show there was an arrow and confirm that it was correct in front of basically the entire team. It would've been literally impossible to doubt that they knew what they were supposed to do.
Usually they are supposed to pro-actively ask you that I think. When I had a fracture in my upper arm everyone would ask me which arm it was. The patient is a good independent backup for easy flip/flop errors.
Error correction
> in most jobs people will say new checklists won't work for /them/ because they understand it better than the checklist, or because the checklist will slow them down.
I fought this fight for a long time as an executive in charge of ops with a team that had a critical enterprise product and refused to use source control.
Sharpie marking for surgery before you're out of it seems pretty common, at least the ~3 times I've had anything done on one side.
Why not put all post surgery patients through a cheap metal detector? Would at least catch stainless steel instruments.
You'd need to do it before you close them up. Maybe a sterile wand?
My understanding is a lot of these things get RFID tags so they can be identified.
And barcoded for quite some time.
https://youtu.be/9GKogq44qHE
> In the airline industry they have checklists
Yes, and The Checklist Manifesto (which is a fantastic book) was published in 2009; yet it seems little progress has been made since.
It's not just checklists, though, it's also basic CRM. If the lead surgeon is God, and you're a nurse, you don't speak up -- you probably don't even believe your own senses when they tell you something's wrong.
A fundamental change is sorely needed -- not sure what will make it happen.
The Checklist Manifesto is good, but it was a little confused over what checklists are.
Almost all of the examples discussed are actually checklists: before you do something, you go over the checklist and make sure whatever it says to do has been covered.
But the example of soap distribution in India isn't like that at all. The notional "checklist" was a list of several circumstances in which you should use soap:
1. Before preparing food.
2. After using the bathroom.
3. After wiping an infant.
4. [There were others; I don't remember them.]
This is a good and valuable set of information to publicize. But it isn't a checklist. Interpreted as a checklist, you would need to check it before and after every action you ever take. That is obviously not something people can do. You use this list by doing the work of modifying your relevant habits to include "wash with soap" at an appropriate stage, which is exactly the kind of approach to doing things that the rest of the book is telling you doesn't work.
There absolutely exist checklists for safe surgery as well, most famously the WHO Surgical Safety Checklist [pdf]: https://iris.who.int/bitstream/handle/10665/44186/9789241598...
It's definitely widely used in Germany, where I work. I don't know how common it is in the US, though.
I often think about what makes medicine so different from aviation and your other examples, culture-wise. It's not like there's no safety culture at all in medicine, but clearly these kinds of structures are deployed to a much lower extent.
One major reason might be the far larger diversity of possible situations in medicine. It's possible to make a checklist for surgical safety because every surgery is similar, same to how every plane flight is similar. But if I think about, for example, harm due to adverse effects from medications, or missed abnormal values in blood tests, it feels very difficult to create a checklist to prevent those that would be specific enough to be useful, but also general enough to capture all important situations these might arise in.
In this sense, I think certain “low-hanging fruit” of safety culture improvements have already been captured in medicine. Apart from surgical safety, I can think of check lists for chemotherapy administration, for blood transfusions, for management of a severe allergic reaction, and other specific individual things. Pointing and vocalizing is also done in surgery, albeit in a less formal way. “Two sets of eyes” policies exist in e.g. pathology for more certainty in diagnosis of cancer.
Nevertheless there is clearly room to improve, as evidenced by the continuing occurrence of “never events” such as retained foreign bodies in surgery. There are certainly economic factors at play here as well: unlike in the free market, in the medical system there is often very little economic incentive for quality, and the same principle I mentioned before — of the immense diversity of possible situations — makes top-down regulation very tricky.
Maybe part of it is also that the potential harm from a retained foreign body is much lower than the potential harm from a plane crash. And maybe medical care is so much more common than plane flights that by base rate alone, mistakes in the former will be much more common. Yet I still think there is much that can be done, and I am unsure what exactly is preventing that from happening.
> One major reason might be the far larger diversity of possible situations in medicine
Yes but the major is the number of deaths. An incompetent surgeon can kill at most one person at a time. Besides, variance in surgery is much higher than in aviation.
Also, if the pilot screws up, he can die too. Surgical screwups are not going to kill the surgeon.
not to be pedantic, but the examples you're describing are _process_, not _culture_.
Examples of culture would be: do nurses feel comfortable speaking up / questioning the lead surgeon? do surgeons feel like they can voice when they're overworked without fear of being perceived as a failure?
What kind of jobs is the rope rigging supposed to handle?
(I think knots are cool, but I don't really know of motivating examples for why I would hypothetically need them.)
As a comparison in the UK there is robust mandatory reporting on "Retained foreign object post procedure" which is a so-called "Never Event" in the most recent publication (April 2024 to September 2024) this occurred 60 times[1] in the NHS in England. For a denominator there are approximately 21 million operation performed in a year by NHS England[2]. So roughly 0.002% of cases have an unintended retained object or roughly 1 in 50,000.
For further reading the Health Services Safety Investigations Body in the UK (like the NTSB but for healthcare incidents is the best worst analogy) looked at retained foreign objects and published in 2024: https://www.hssib.org.uk/patient-safety-investigations/retai...
[1]: https://www.england.nhs.uk/long-read/provisional-publication... [2]: https://digital.nhs.uk/data-and-information/publications/sta...
My mother had rags left in her during a surgery that ended up fucking up the course of her life forever and leaving her permanently disabled. The rags didn’t cause the primary problem, but were just a part of their shoddiness.
Of course it’s not every surgeon, but there are some butchers that out happens more with. It ended up being a repeat problem for my mother’s surgeon.
When my wife had some minor surgery (not fully anesthetized), there was a nurse present who counted all of the sponges, etc. that were used, then made sure there were that many on the tray at the end. They didn't match up, and it turned out that the surgeon had dropped one off of the table.
The article mentions that counting is standard procedure, so hopefully this is how it works everywhere. It definitely seems like having someone who isn't the surgeon doing the counting would be the way to go. The surgeon is already very focused and it's easier to say "I'm sure I didn't leave anything" when someone else isn't telling you otherwise.
Doctor here (non-USA). This is standard procedure and has been standard ever since I was a medical student, almost 20 years ago. The "running nurse" is in charge of maintaining a count and making sure that nothing is left inside the patient.
Swabs and towels tend to come in pre-prepared packs, so the nurses have another source of truth. Any mismatch between the preprepared count, running count during the operation, and actual swabs/towels laid out at the end is a serious cause for concern. You will not close up a patient if there is a mismatch.
Yeah, back in the late 90s I was able to observe a number of surgeries (different story) and I remember the counting being almost fanatical. They had what looked like a shoe holder that hung on a door for putting each rag that was used. Every instrument that was used was accounted for during and after. The surgeon was definitely not the counter.
My wife is an OR nurse and jokes her primary job responsibility is counting. Frequently when surgery is going long it's because someone threw out or dropped something that was supposed to be accounted for and they won't close the patient up until that's found, even if that means sorting through the garbage.
This is definitely a thing, they do all kinds of things like counting things before and after the surgery to avoid it.
Fifteen or 20 years ago I remember seeing something about using bar codes to "check out" and "check in" all the tools so nothing was unaccounted for. Unclear if that system's been widely adopted, though.
They do something like that in aircraft manufacturing - every tool has a dedicated spot in the toolbox and a job can't be signed off unless all the tools are back in the toolbox. Bolts, nuts, and other parts/debris are a different story though... there's horror stories from that as well, especially recently from one of Boeing's facilities implicated in the string of manufacturing and maintenance related incidents Boeing had in the last couple years.
"Dottore, still counting ? Hurry up, there are 10 more patients avaiting surgery today. The profit of the company and your bonus are in danger. Hurry up"
You could frame it a different way; what level of risk would be acceptable vs. the reduction in cost/time/use of resources. If you're 10% faster for 0.1% risk, is that a better outcome for society?
You could, but the willingness to frame it that way at a local decision-making level causes problems for global optimization. It's perfectly fine for a surgeon to triage patients and actions. It's much less fine for a hospital administrator to decide they can get away with less staff because the increase in risk isn't _that_ high (maybe only a couple extra deaths per year). Perhaps it's fine to make that tradeoff, but the blatant conflict of interest and history of people doing worse things for less money suggests it should at least have oversight.
Society isn't a shareholder
How would you feel being the 0.1% for the betterment of society? Your sacrifice is appreciated!
We are all already part of this conversation, all the time, because resources are finite
The flip side is "sorry, we didn't have enough surgeons available right now so we have to triage you", or, "sorry you can't afford the bill"
I'm sure in this particular situation the numbers benefit "don't leave surgery debris in the patient" but the more general point remains, there is some set of numbers (likely implausible) where it would flip the other way
Hate it all you want but these decisions of how much percentage death is legally allowed happens whether you like it or not. Otherwise we'd have no cars on the road, no planes in the sky, no boats, no swimming, no cycling, etc
10% faster could easily be more than 0.1% better for society. Less risk for infection or other problems, more people can be seen etc. Its entirely about weighing pros and cons and you are being ignorant by assuming otherwise.
Not all surgeons are alike, just as in any profession: some make many errors and some make few. But doctors unions fight tooth and nail to prevent the publication of information that would allow patients to make informed decisions about their surgical provider, which removes the financial incentive for surgeons to do better and prevents bad surgeons from being weeeded out of the market.
> But doctors unions fight tooth and nail to prevent the publication of information that would allow patients to make informed decisions
Yes.
> which removes the financial incentive for surgeons to do better and prevents bad surgeons from being weeeded out of the market
This is absolutely not why the 'doctors unions' fight against performance statistics. Can't you people think of nothing else than money ?
unlucky for you we have a control group with Canada's public health system where surgeons still leave things inside people and no efficient market to "weed them out" so I don't think this is correct
Seems there should be a "check in" "check out" list, managed by one of the other staff, and double checked by another, ideally.
Or even some form of RFID tagging and a scan wand.
In my previous life I once taught a theatre production class in which one of my students was a surgical nurse. She was fascinated by the prop table. For those of you who don't know, standard procedure - at least with every Stage Manager with whom I ever worked - for a prop table is to draw an outline around every item, which in one step defines a place for everything and allows one-glance inventory assessment. Well, this nurse said she hadn't seen or thought of that approach, which would speed up and make more reliable the "count in and count out every surgical instrument" part of her role, and she vowed on the spot to implement it at work.
It's the only time in my theatre career I might have maybe indirectly saved a life.
That’s a brilliant idea that’s exactly what it should be! Wow, how about we found a medical device company that’s like a table that will let you know when the device it needs is not back on the table? Seriously I always wanna get into hardware. cris@dosaygo.com
Though honestly, I’m sure you saved many other lives directly or not by theater that speaks to people, that they can identify with.
I do the same for my wall of tools, and it's also helped my partner remember to put them back after she borrows one. (But it makes me grumpy when one gets lost and I can't find a replacement that's the same size and shape).
https://archive.ph/xm5L0
https://archive.is/XeY5j
This sounds like the perfect application of image processing and machine learning. A computer with a camera attached could monitor the whole operation and warn the surgeon if it detects an object going in but not out.
At least it would be more useful than the system they use for self checkouts at my local supermarket. "Did you forget to scan something in your trolley?" Yes, it's my child.
maybe? If you've every seen a non-trivial surgery there are lots of people, action and "things inside you". I'm not convinced we should or even can optimize for camera field of view and ML - especially when this feels more like an accounting problem than an image processing problem.
I wonder how the frequency compares with other countries. Is this as common in Europe or in Asia? Or even Mexico or Canada?
Unworthy.
At least in America, surgeons are part of an entitled medical elite, and there is tragically little interest in holding them to account. Let alone forcing them to do better.