Haraden, who travels the world speaking to doctors and hospitals about changing their culture, says the only way to get people to change is by showing them data that underscores how standards and teamwork reduce errors. Then leaders of hospitals have to make it clear that they expect their staff to follow the protocols, and hospitals need to report information about errors so the public can compare their safety records.
"This is a very, very new set of learning and behavior expectations that haven't been true in health care," Haraden says. "It takes time. We have to have this conversation over and over again with every person."
Some of the data Haraden uses in her talks comes from Atul Gawande's 2009 book, The Checklist Manifesto: How to Get Things Right, in which Gawande, a surgeon at Brigham and Women's Hospital in Boston, ponders his own fallibility and explores how to help others in health care.
"Avoidable failures are common and persistent, not to mention demoralizing and frustrating," Gawande writes. "We need a different strategy for overcoming failure. And there is such a strategy--though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies. It is a checklist."
To create his list, Gawande looked to the aviation industry, a high-risk sector that has become reliably safe in part because everyone uses checklists. The military began using aircraft checklists in the 1940s when the complexity of planes reached the point that pilots couldn't remember every step needed to fly the plane. As Gawande describes it, the checklist included seemingly "dumb" things such as making sure brakes were released, doors and windows were shut, and instruments were set. But when something becomes habitual and mundane, it's easy to forget. And overlooking any of those steps could cause a plane to crash.
Today there are multiple checklists for each aspect of airplane operation, including what to do if something goes wrong, such as an engine failure during flight.
Aviation checklists also encourage discussion and spread power among those in charge, creating a sense of teamwork. Assisting pilots participate in checklists and are encouraged to question their commanding officers if they sense there's danger. The idea is that there's "wisdom in the group" over the individual, writes Gawande: "Man is fallible, but maybe men are less so."
Gawande took what he had learned from the aviation industry and worked on a checklist that covered mundane but essential tasks and fostered communication. He developed the list with other doctors through the World Health Organization, and the tool was deployed in eight hospitals worldwide in 2008. The results were telling. Hospitals that adopted his checklist reported a 36-percent drop in major surgical complications and a 47-percent decline in deaths, according to Gawande.
The hospitals reported that the list provided backup protection against lapses in memory due to fatigue or distractions. It also encouraged preoperative discussions, which came in handy when the unexpected occurred during surgery. "No one checklist could anticipate all the pitfalls," Gawande says, so just having hospital staff stop to talk through a case and its potential challenges reduced complications and deaths.
Dr. Michael Zenilman, regional director of surgery at Johns Hopkins Medicine in the National Capital Region, says physicians have resisted using checklists because "we believe we are different from the rest of the world." But Gawande's book has helped change minds.
Suburban Hospital began implementing a checklist in early 2011 just before Zenilman arrived in his job to align surgical care at Bethesda's Suburban, DC's Sibley, and Howard County General Hospital. All three belong to the Johns Hopkins Health System.
To demonstrate how a checklist is used, Zenilman invited me to watch a gallbladder surgery last August.
Suburban's checklist is modeled on the one Gawande developed with the WHO. It has three parts: one to be completed right before the patient is anesthetized, one right before the patient is opened, and one before the patient is wheeled out of the operating room. Each part provides moments for staff to stop and talk about potential problems.
The first part includes a confirmation of the patient's name, the type of procedure, whether the surgery site has been marked, and whether the anesthesiologist has any concerns. The second includes identification of the patient again and an introduction of everyone operating on the patient that day, plus ten other items such as what time an antibiotic was administered. The last part asks if there have been any equipment failures during the surgery, what tissue specimens have been taken during the operation, and whether all surgical equipment has been accounted for to ensure that nothing is left inside the patient. Each section is supposed to take about a minute to complete.
On the day of the surgery, each part of the checklist was encased in a plastic sheet and posted on a wall near the operating table. The circulating nurse that day, Megan Dinsmore, called out each item on the list and then used a black marker to check them off.
"I did a checklist before, but it was by memory," Dinsmore said. "This is much easier."
But she left on a break about halfway through the surgery and was replaced by Jessica Moscati. At the end of the operation, the patient was wheeled out of the room, and no one had checked off the third part of the list on the wall.
When I asked her why, Moscati told me she had conducted the third part of the checklist orally--including the count of instruments used in the surgery. Zenilman said he wouldn't have been permitted to finish his surgery until the instruments were counted. When pressed on why they didn't physically complete the checklist, Moscati said: "We should have."
Next: How hospital staff can work together to prevent accidents from happening
In a follow-up interview, Zenilman came to Moscati's defense. "What the checklist is doing is putting in writing a process of events that are already happening," he said. "You saw the third part is making sure the pathology report is sent off and making sure the count is right. Those things were done."
Hospitals that don't follow their own patient-safety protocols 100 percent of the time can't get to 100-percent safety, says Jeffrey Selberg, chief operating officer of the Institute for Healthcare Improvement, a nonprofit in Cambridge, Massachusetts. "If Suburban's process dictates that they document on the checklist, then they need to document on the checklist," Selberg says.
"What shouldn't be lost," he adds, "is that Suburban was willing to have you observe and you felt you could call them out and have a dialogue about it. That is great. I think it's terrific that the nurse said, 'We should have done the checklist.' That speaks well of them."
To get to 100-percent compliance, Selberg says, hospital staff have to feel free to talk about mistakes and what they learned from them.
For a long time, many health-care providers believed it was inevitable that some small percentage of intensive-care patients would get infections after the insertion of a tube, catheter, or ventilator, often for multiple days, to keep them alive.
But Peter Pronovost, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore, proved them wrong. Dr. Pronovost began using a checklist at Johns Hopkins that led to a 90-percent drop in bloodstream infections in the hospital's intensive-care units and that in some cases got the infection rate to zero.