Killing Fewer Patients


Doctors insert tubes—catheters—into patients’ veins about 5 million times a year. Until recently, forty thousand of these patients died annually of the resulting infections, which are shown as “complications” from operations.

The Center for Disease Control has published an excellent 120-page book on the best way to insert catheters, but the recommendations were so long and complicated that very few medical personnel followed them.

At Johns Hopkins Hospital a specialist named Peter Provonost thought a checklist for this procedure, like the ones used by airplane pilots, would reduce error. Consulting co-workers, he devised a five-part checklist: 1. Wash your hands using soap or alcohol; 2. Wear sterile gloves, hat, mask and gown and cover the patient with sterile drapes; 3. Avoid placing the tube in the groin, if possible; 4. Clean the insertion site with antiseptic solution; 5. Remove the tubes when they are no longer needed.

This checklist was distributed to the Johns Hopkins surgical intensive care unit. To the dismay of all concerned, it wasn’t followed! Only 38% of the time did the doctors concerned perform all five steps. Thus, most of the patients were exposed to the risk of infection…possibly lethal infection.

What to do? First, one needed to collect all the necessary equipment—tubes, masks, drapes, etc.—in a convenient place, rather than having to send nurses scuttling hither and yon to scrounge up the different items. So the hospital collected everything needed on one cart, which could be wheeled up to the scene as needed.

Hurrah! The performance rose to 70%. Better, better, but still 30% of the patients were being exposed to a lethal and unnecessary hazard.

Now came the hardest part. Doctors get used to being infallible. They work at the highest level. Trifles are distractions. Still, faced by the facts, they reluctantly caved in, and permitted the nurses to check their compliance with the checklist. This turned the hierarchy upside down. Doctors command nurses, not vice versa.

Nevertheless, after much haggling, the doctors submitted. In each operating room a nurse maintains the checklist for catheter insertion. And with that, the infection rate plunged within a year to approximately zero!


The whole episode reminds one of  Pasteur’s struggle to get his fellow doctors in Paris to accept the idea of antiseptics. It took forever, but after years and years he prevailed. It seems that disturbing the established routines of a guild, like doctors (or lawyers) challenges the authority, their position, their existence.

And for that matter, one mustn’t let the checklist become congealed. Things change, and checklists must evolve. There’s a wonderful Latin tag on this subject: TEMPORA MUTANTUR NOS ET MUTANTUR IN ILLIS. “Times change and we change in them.” I used it as the epigraph of one of my investment books.

It has been learned that an effective checklist should be no longer than five to nine items, should be simple and concise in language, and should not include fancy colors and diagrams. Just clear prose—one, two, three, four, five.

Now, in any event, the problem is to get the word out to all the other hospitals in America, and eventually, the world. Good luck!