Checklist dei corsi

So for me it was great to find discussions, referencing a study published in the New England Journal of Medicine that found (amazingly?) that hospitals using checklists in their operating room procedures suffer a much lower death rate than those that don’t.

I was glad to see the study, but still my very first reaction on reading it, was really outrage, along the lines of “Why was a study like this even necessary? Operating Rooms don’t routinely use checklists?  What the (expletives deleted)?”
Hopefully the study will ratchet up awareness some and perhaps drive some improvement. (This also gives some indication of the opportunity for improvement in the medical system.)

But experience has absolutely convinced me, that there is something in the human psyche that fights back desperately against using checklists.

“We need to get things done quickly. Checklists will slow us down. We know what we’re doing; we’ve done it a zillion times before.”

Best intentions in the world. Just not a correct statement.

Generally we found on packaging lines, that any missed item on a changeover checklist cost us at least 10 minutes of lost time on startup. In several cases it resulted in some really significant equipment damage, and who knows how many other times, there were damage near misses, or safety near misses. Settings that weren’t changed, bolts that weren’t tightened, clamps left loose,All completely unintentional, done by people who had done it many, times before.

Human memory just isn’t reliable enough, especially if interrupted to briefly do something else, or perhaps someone has a question, or needs a hand momentarily. Once the mind has changed focus, all bets are off on memory.