Good afternoon everyone. First, I would like to thank the organizers for the invitation and opportunity to share with you what I have learned about Checklists

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Number of people visiting a medical facility per year (USA) (physician offices, hospital outpatient and emergency departments): http://www.cdc.gov/nchs/fastats/physician-visits.htm

Number of people flying per year (Globally) : http://www.iata.org/pressroom/pr/Pages/2013-12-30-01.aspx

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Medical Events in radiotherapy … It might be that you or someone that you know has participated in one or many events and mistakes…if you have not, the New York Times did a very good job describing the nature of our field, the risks that patients are expose to, as well as showing what happens when things go wrong. If you have not read it, I would highly encourage you to read it, specially the article describing Mr. Jerome-Parks story.

I often hear that because of we commonly deliver the radiation in multiple fractions, that we can correct for mistakes, in the case of Mr. Jerome-Parks, there were only three of out of 35 fractions, and there was no way to correct for that.

You might be thinking, I have a very good safety program, I have good processes, I perform my IMRT QA every time, there is no way that events like this one, where there was something obviously wrong, can happen to me.

But what about the more subtle errors, like not following a clinical protocol 100%, can this affect our patients outcomes?

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Well, it actually does. These are the results of a large international phase III trial evaluating radiotherapy with concurrent chemotherapy (cisplatin plus tirapazamine) for advanced head and neck cancer.

On this analysis they study the clinical impact protocol compliance…Red line shows noncompliant with predicted major adverse impact on tumor control. Poor quality is affecting outcomes, specially overall survival, by a considerable amount

They concluded how sobering it was to note that the value of good radiotherapy is substantially greater than the incremental gains that have been achieved with new drugs and/or biologicals agents.

What can we do about it?

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Well, it actually does. These are the results of a large international phase III trial evaluating radiotherapy with concurrent chemotherapy (cisplatin plus tirapazamine) for advanced head and neck cancer.

On this analysis they study the clinical impact protocol compliance…Red line shows noncompliant with predicted major adverse impact on tumor control. Poor quality is affecting outcomes, specially overall survival, by a considerable amount

They concluded how sobering it was to note that the value of good radiotherapy is substantially greater than the incremental gains that have been achieved with new drugs and/or biologicals agents.

What can we do about it?

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Checklists are one of many tools available to mitigate errors. Checklists have….

As I was preparing this presentation, I found that there is an organization called Aviation Safety Network and they keep track of statistics about actual fatal accidents and casualties in aviation world wide. Do you know the number of aviation fatal accidents in the last 5 years? 20 – 30 Do you know the number of casualties in the last 5 years? 300 to 1000 people world wide– this is excluding military transport and hijacking.

According to the iata :http://www.iata.org/about/Documents/iata-annual-review-2013-en.pdf

Now let’s compare it to the medical industry….How many people die every year because of preventable medical mistakes? 1999 Institute of medicine claimed that 100,000 people die every year of preventable medical mistakes.. A new study published publish on the Journal of patient Safety estimated that 200 to 450 thousand people die every year of medical error, according to this study. Medical errors is third cause of death after heart disease and cancer…

This make me think, next time that I see a person that is panicking in plane, I may

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say, we should be thankful that we are not in an ambulance heading toward a hospital…

Any way.. Let’s continue with checklists..

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Peter Pronovost and Atul Gawande are two of the most famous cases where checklists played an important role.

To the medical field..

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Gathered all the knowledge from current best practices . Fits perfectly with the MPPG definition. Put emphasize on safety culture improvement.

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Two basic categories depending on the type of behavior needed for completion

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How does it works?

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What so difficult about checklists? I can do checklists for groceries, trips with the family, etc.

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Emphasize the human component. -> we are more complex and cognitive abilities

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How can we make checklists work.

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Change paradigm of the one person in charged – review Beyond Checklists

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Accountability from all members on the group to commit to the concept – Top perspective matters

Basically the team should feel empowered to stop the treatment

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Checklist as a tool has its own limitation so selection of the tasks is important

Everything that we do is time management!!! So look for those areas that gives you the most for your time!

Example Dosimetry – Plans

Plan Check

Chart check

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Outcome and performance evaluation, specially important for checklists to convinced the skeptics.

Error proving

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Example of the family traveling

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Getting representative all the groups -> Help to get people involved so they believe in the tool.

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Use ion chamber example

“We cannot change the human condition, but we can change the conditions under which humans work.”- James Reason

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Several months. Strict implementation process

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I do not claim that checklists are the ultimate solution. As I mention at the beginning of the talk, Checklists are one of many tools that we can use to prevent mistakes. Specially on those tasks or situations that require human intervention.

But let’s just assume for a moment that one of you designs a simple checklist which is supported by a strong safety culture, by using your checklists you demonstrate improvements in outcomes and can actually move this curve up.. or by using your checklists you catch a big error that could have made the difference between a terrible outcome and the continuation of a happy and fulfilling life…..

Wouldn’t you like to use it?

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