<\/span><\/h2>\n\n\n\n\n page 7-10. Philosophers essay on errors distinguishes between errors of ignorance and errors of ineptitude. The first seem more forgivable than the second, but in the context of performance of complex activities under time pressure. the latter seem inevitable.\n<\/p>\n\n\n\n
\n page x. A patient in an intensive care unit undergoes 178 procedures a day. \n<\/p>\n\n\n\n
\n page 38. Using a checklist to make sure 4 steps were carried out reduced the 10-day line infection rate from 11% to 0. Other examples showed reductions from 41% to 3% for untreated pain, and 70% to 4% in improper procedures for those on mechanical ventilators (resulting in a 25% decrease in cases of pneumonia). \n<\/p>\n\n\n\n
\n page 43-44. In the Keystone initiative, getting project manager and executive participation in checklist roll out was key. Executives made sure that the required chlorhexidine soap was available (previously it was available in only 1\/3 of the ICUs), and that required sterile drapes were stocked. After a while, the supplier of lines was persuaded to produce a kit that had both the soap and drapes in it. \n<\/p>\n\n\n\n
\n page 46. In a checklist deployment to hospitals to reduce cardiac arrest fatalities, checklists were deployed to first responders (rescue squad personnel) and first coordinators (hospital operators) even though they were the least powerful. This enabled the organization to prepare by being alerted ahead of time and mustering the needed skills. \n<\/p>\n\n\n\n
\n pages 65-68. The building construction checklist of both instrumental tasks (put together by 16 disciplines and looked over by subcontractors), and communications activities (\u201cthe submittal list\u201d \u2013 who talks to whom when about what). By ensuring that the right people are charged with talking at the right time, you radically lower the need for a single person to understand all the details of what is going on. \n<\/p>\n\n\n\n
\n pages 76-80. Walmart and Katrina and empowering store owners. And Van Halen and brown M&M story as a procedural integrity check. \n<\/p>\n\n\n\n
\n pages 95-97. The Proctor and Gamble soap in India study. The use of soap was made more systematic, and more pleasant. \n<\/p>\n\n\n\n
\n pages 99-100: \u201cCleared for Takeoff\u201d checklist for ensuring timely administration of pre-operative antibiotics. A mechanical forcing function (a metal tent stenciled with \u201ccleared for takeoff over the scalpel that served as both a prompt and a legitimation of the nurse\u2019s role in the process. Increase in proper antibiotic administration went from 60% to 89% (3 months) to 100% (10 months).\n<\/p>\n\n\n\n
\n page 103. \u201c\u2018That\u2019s not my problem,\u2019 is probably the worst thing people can think, whether they are starting an operation, taxiing an airplane full of passengers down the runway, or building a thousand-Foot skyscraper. But in medicine, we see it all the time.\u201d\n<\/p>\n\n\n\n
\n pages 107-110. Introductions among team members increase team affinity and empower lower status members to speak up. \u201cWhen nurses were given a chance to say their names and mention concerns at the beginning of an operation, they were more likely to note problems and mention solutions.\u201d Employee satisfaction rose 19% and OR nurse turnover went from 23% to 7%\n<\/p>\n\n\n\n
\n page 120. Good vs. bad checklists. Would be nice to know more about this, rather than the obvious and rather sloganish comments in the book. \u2026Nice point about getting leadership to adopt checklists first.\n<\/p>\n\n\n\n
\n pages 154-155: WHO Safe Surgery Checklist results. Double-digit reductions. \n<\/p>\n\n\n\n
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