TheWHO SurgicalSafety ChecklistA brief history (with Lego)

built byDr Thom O'Neill

Raigmore Hospital NHS Highland

Scotland

The Checklist

Atul Gawande

Why do people die from simple

errors?

The Super-Specialist

No more Masters

The Burden Of Knowledge

Human Fallibility

Ignorance

Ineptitude

How do we reduce harm?

The Checklist

ComplexityTheory

The Glasgow Subway:Simple

The Early London

Underground:Complicated

Complex

Construction

TheMaster Builder

Too much for one

individual

Complicated

Aviation

Individual Skill

Complex

The Hudson RiverEmergency

Article 126

Healthcare

Where to start?

Who should lead it?

Is the correct site marked?

Initial barriers

Anaesthetic machine

Prophylaxis

Drugs checked?

Expected blood loss

Eight major cities

Large and small centres

35% 47%

Complications Deaths

SURPASS Trial47% reduction mortality

Checklist in 2008Flat death rates pre-20080.06% fall in rates per year sinceEst. 9000 lives saved

Ontario study9% fall in deaths(0.71% to 0.65%)Design problems (20% ophth)Government mandatedMeasured at 3 months

Mandate without training

Medics

Central lines

Pre-hospital