If you think about it, your humorous version shows that it's not as easy as just "using a checklist."
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I know, it's a stretch but people of good intention commit such errors unless the system makes it almost impossible to do so. Another issue: when you have used a given checklist 1000 times, it is hard to avoid not paying close attention to it.
Aviation and nuclear power have among the best error prevention, detection and correction systems in the country. Medicine is making rapid gains but has a long way to go.
I think the medical profession has a lot to learn, aviation and nuclear are probably good places to learn from. Even the thought that there would not be some long established SOP on "X marks the spot" or "X marks - do not touch" is an indication of systemic problems. More to the point, "X" is a bad way to do it, "X" does not communicate a specific, non-ambiguous action, it requires a "decoder ring" to know what it means. Not good.
You're right, a checklist alone gets stale pretty quick, you need a checklist and checks-balances on that checklist that keeps people involved. Such as one person reading the list, another responding with data, not just "check, check, check, check...." (ooops, was that 4 'checks' or 5 'checks', ....whatever). It's tougher to get complacent with "Oxygen? - Oxygen reading 4.5"; " BP? - BP reading 110/85"; "Marking on limb to amputate? - 'cut here' marked on right arm to amputate at elbow, "save' marked on left arm", etc. ( fill in with much more official sounding medical lingo
).
We used closed-loop-checks-balances for things far less important than someone's organ or limb. I've been shocked at how lax the medical industry is on these things. A friend of ours is a pharmacist. I asked her about how the heck they know what to do with that scribble on an Rx pad. She said something causal like "Oh, there are typical meds and typical dosages, we know you wouldn't get 100mG of a certain medicine - must be 10mG because that's typical. If something looked out of the ordinary we would call the Doc". It was just unfathomable to me that there wouldn't be some formal checks-balances in something like that.
Now, when you present engineers with a checklist and checks-balances, some of them get offended. "I know what I'm doing - that's what you pay me for", some will say. They feel like you don't trust them, or they are being treated like children. I suspect this is an issue with a lot of Doctors. You have to get them to understand that it's not about "them", it's about having a system in place that can be relied on to limit errors. And if an error does occur, having a system in place means you have something to improve. Without a system, how do you make it 'better'? It's really hit-or-miss.
One of the problems is the incredible workload on the operating team.
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I know this is no excuse for the mistake that happened but to me with all the cut backs in hospitals I'm amazed that more mistakes do not happen .
I don't doubt it, but not many people claim they have a lot of extra time for extra checks-balances. But as I said above, w/o it, not only will 'stuff happen', but it won't get better, because there is no basis to build upon. We often found that well designed checks-balances
reduced our workload, we knew who was doing what, knew if it was done, and didn't waste time doing things twice or waiting for something we thought was done already. Things ran smoother, with less stress, which means you apply more mental power to the things that really need it. You might catch something else that you may have missed because you were distracted by something that wasn't ready because you didn't have a check-list. It's not always a time adder. It can be a pain getting it started, but once you have a good system in place, you wonder how you lived w/o it. That was my experience. Checklists and checks-balances designed to help you get the job done, not just to say you have a checklist.
-ERD50