Every Year 30,000 patients die because of infections in central venous catheters. Many of these infections come about because about 30% of doctors simply forget to wash their hands.
If nurses and doctors use a simple 5 point checklist (recently upgraded to 19 points) the incidence of these infections is reduced by as much as 66%. If hospitals all over the nation used the same checklist as many as 28,000 lives could be saved with a reduction of associated cost of these infections of $2.3 billion.
In 2001, Peter J. Pronovost, M.D., Ph.D., a practicing anesthesiologist and critical care physician, outlined a simple protocol to prevent catheter-related bloodstream infections. He now has a book out called: Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.
The checklist was pretty simple: Doctors are supposed to (1) wash their hands with soap, (2) clean the patient's skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in.
If a doctor forgot one of these steps the nurses were supposed to remind them. That caused a huge flare up because doctors do not want nurses criticizing them in public and nurses are intimidated. Still both doctors and nurses were encouraged to use the checklist and the results were dramatic.
The number of 10 day infections dropped from 11% to zero!
People think these points are so simple that they don't need to be reminded, but doctors are overworked and they are constantly thinking of so many other things that every doctor makes simple mistakes.
The idea of a simple checklist came from the use in aircraft. Perhaps we should expand the use of checklists to many other operations. Medicine has become so complex that a checklist that simplifies everything to the basics is crucial.
http://www.nytimes.com/2009/12/24/books/...Iatrogenic(doctor-related) causes are the third largest cause of death in the United States, causing 300,000 deaths a year. See:
http://www.flcv.com/iatrogen.htmlAn interview with Peter J. Pronovost about patient safety has some good ideas about how to reduce those deaths.
http://www.commonwealthfund.org/Content/...