Dott Risk promote a systematic approach to risk management, part of which is the active use of Checklists and Assessments. This systematic and disciplined approach to risk management is often used in highly complex situations and industries, with high profile examples including F1 pit crews, airline pilot crews, the hospitality industry and surgical theatre teams.
They have proved their effectiveness by establishing clear responsibilities and accountabilities and a standardisation of complex procedures. They also remove the potential influence of strong or authoritative personalities and eliminate human fallibility. The use of Check-lists in these environments has seen a major reduction in errors, accidents, deaths and has saved considerable lives. Check-lists compensate for the inbuilt tendency of human beings under stress to forget or ignore what is important, including the most basic things.
Extending the use of Check-lists and Questionnaires as key tools for risk management in any business will produce similar results and eliminate and reduce many potential losses.
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Taking a systemic approach to risk means understanding that bad outcomes are almost never the result of a single fault, failure, or error, but instead are the end result of a causal chain of events. It also means realising that we can no longer define safety solely as the absence of accidents and incidents. We must go beyond that to look proactively at risks and mitigate them before they can lead to an accident.
Check-lists compensate for the inbuilt tendency of human beings under stress to forget or ignore what is important, including the most basic things. In the case of an operating theatre environment, they empower the people at the edges of the room before the operation and at key moments during it, the whole team goes through each point in turn, including emergencies, which gives a cue to more reserved members of the team to speak up.
The World Health Organisation (WHO) surgical safety check-list was launched in 2008 to improve teamwork and thus combat avoidable complications in surgery, such as retained swabs and instruments.
Despite the positive impact the provision of surgical services can have on a population’s health, surgery itself carries risk. Current estimates of morbidity and mortality following surgery indicate that over 7 million people worldwide will suffer complications following surgery. One million of these people will die as a result. Around half of these complications are potentially preventable, so using the Checklist to improve the safety of surgery will save many thousands of lives each year.
Use of the WHO Surgery Checklist reduced the rate of deaths and surgical complications by more than one-third across all eight pilot hospitals. The rate of major inpatient complications dropped from 11% to 7%, and the inpatient death rate following major operations fell from 1.5% to 0.8%.
What is the Checklist?
The WHO Surgical Safety Checklist is a simple tool designed to improve the safety of surgical procedures by bringing together the whole operating team (surgeons, anaesthesia providers and nurses) to perform key safety checks during vital phases of perioperative care: prior to the induction of anesthesia, prior to skin incision and before the team leaves the operating room.
Why is the Checklist important?
Surgery can be a life-saving or life-changing intervention in many conditions and the provision of surgical services is being increasingly recognized as a significant public health issue. A modeling study estimated that 234 million operations are carried out every year across the world. This translates to one operation for every 25 people and is more than the number of children born worldwide each year.
The story of United Airlines flight 173 which crashed on a clear evening in 1978 is known to every airline pilot, because it is studied by every trainee. To the great credit of the aviation industry, it became one of the most influential disasters in history. Galvanised by this incident and a handful of other crashes from the same era, the industry transformed its training and safety practices, instituting a set of principles and procedures known as Crew Resource Management (CRM). A psychologist called Alphonse Chapanis had recognised that human beings’ propensity to make mistakes when they are tired is much harder to fix than the design of levers and controls. His deeper insight was that people have limits, and many of their mistakes are predictable effects of those limits. That is why the architects of CRM defined its aim as the reduction of human error, rather than pilot error. Rather than trying to hire or train perfect pilots, it was better to design systems and procedures that minimised or mitigated inevitable human mistakes. In the 1990s, a cognitive psychologist called James Reason turned this principle into a theory of how accidents happen in large organisations. His underlying message was that because human beings are fallible and will always make operational mistakes, it is the responsibility of managers to ensure that those mistakes are anticipated, planned for and learned from. Without seeking to do away altogether with the notion of culpability, he shifted the emphasis from the flaws of individuals to flaws in organisation, from the person to the environment, and from blame to learning. In the BBC science documentary (Sep 2013) titled Life, Death and Mistakes the presenter of the programme, Dr Kevin Fong, co-director of the Centre for Altitude, Space and Extreme environment medicine, re-iterated the point that we are all human and as humans, are fallible and prone to making mistakes. He made the point that there are however things we can do to reduce this, such as following protocols, adhering to procedures, following check-lists and standardising processes. He concluded by saying that human error will always be with us but it is how we deal with it is what matters in making us less fallible.
Captain Chesley B. “Sully” Sullenberger III became a source of inspiration and hope for millions after his successful emergency water landing of a disabled airliner in the Hudson River on Jan. 15, 2009, dubbed the “Miracle on the Hudson.”
He has delivered a number of keynote addresses since then on the importance of aviation and patient safety and making safety a core business function. Some of the key points he makes have been:
- Taking a systemic approach to risk means understanding that bad outcomes are almost never the result of a single fault, failure, or error, but instead are the end result of a causal chain of events. It also means realising that we can no longer define safety solely as the absence of accidents and incidents. We must go beyond that to look proactively at risks and mitigate them before they can lead to an accident. That has made a huge difference in aviation safety in the past 10 years.
- We are beginning to use the safety management system (SMS) concept in aviation. SMS makes safety a core business function – at least as important as financial considerations – and holds management at every level responsible for safety. That makes safety a transparent part of everyday business. Of course, this approach requires great leadership. It requires a culture change. And it requires that decision makers, who are often far removed from the implications of their choices, come to realise that administrative and budget decisions are also safety decisions.
- Decision makers are often financial experts, but not subject-matter experts; they need to develop an understanding of the science of safety. The leaders, the board members, and the C-suite hold the keys to change. They are the ones who have to lead change.
- Pilots from my generation can quote you chapter and verse on the specifics of all the important accidents that occurred in the past 50 years. For example, when we’re taxiing out for takeoff, we make sure to pick the appropriate point of the taxi that’s distraction-free to begin doing the before-takeoff check-list. We remind ourselves not to be like Northwest Flight 255 in Detroit back in the 1980s; we want to avoid distractions and make sure all the proper steps are completed without interruption. So we sensitise ourselves to findings about the causes of accidents and we remember them.
Check-lists compensate for the inbuilt tendency of human beings under stress to forget or ignore what is important, including the most basic things. In the case of an operating theatre environment, they empower the people at the edges of the room before the operation and at key moments during it, the whole team goes through each point in turn, including emergencies, which gives a cue to more reserved members of the team to speak up.
The World Health Organisation (WHO) surgical safety check-list was launched in 2008 to improve teamwork and thus combat avoidable complications in surgery, such as retained swabs and instruments. When used properly the WHO check-list prompts effective team communication to eradicate avoidable risks such as retained throat packs. The Medical Protection Society in its November publication Casebook states that proper usage of the check-list requires the following;
All three phases of the list must be performed: sign-in, time out and sign out
The anaesthetist must be present for all three stages. Best practice is to have all numbers of the surgical team present for all three phases, although sign in may take place without the surgeon
At sign-in, responsibility for both insertion and removal of throat packs must be assigned
At sign-out, removal of the throat pack must be checked, either as part of the swab count exercise or as a distinct part of the check-list
Despite the positive impact the provision of surgical services can have on a population’s health, surgery itself carries risk. WHO estimates of morbidity and mortality following surgery in 2008 indicated that over 7 million people worldwide would suffer complications following surgery. One million of these people will die as a result. Around half of these complications are potentially preventable, so using the Check-list to improve the safety of surgery will save many thousands of lives each year.
Use of the WHO Surgery Check-list reduced the rate of deaths and surgical complications by more than one-third across all eight pilot hospitals. The rate of major inpatient complications dropped from 11% to 7%, and the inpatient death rate following major operations fell from 1.5% to 0.8%.
Check-lists are most effective in an atmosphere of informality and openness. It has been shown that simply using the first name of the other team members improves communication, and that giving people a chance to say something at the beginning of a case makes them more likely to speak up during the operation itself.
Check-lists are now used extensively by F1 pit crews, Airline pilot crews and surgical theatre teams. They have proved their effectiveness by establishing clear responsibilities and accountabilities and a standardisation of complex procedures. They also remove the potential influence of strong or authoritative personalities and eliminate human fallibility. The use of Check-lists in these environments has seen a major reduction in errors, accidents, deaths and has saved considerable lives. Extending the use of Check-lists to business risk management will produce similar results and eliminate and reduce many potential losses.
The hospitality industry also makes extensive use of check-lists to ensure consistency of service delivery and quality. Macdonalds makes use of check-lists which complement training and an environment with a high turnover of staff. The world’s largest and busiest hotel, the Venetian Palazzo in Las Vegas, makes use of an 83 point check-list as part of its housekeeping management.