INTRODUCTION
7“In the 1970s”: S. Gorovitz and A. MacIntyre, “Toward a Theory of Medical Fallibility,” Journal of Medicine and Philosophy 1 (1976): 51–71.
9 “The first safe medication”: M. Hamilton and E. N. Thompson, “The Role of Blood Pressure Control in Preventing Complications of Hypertension,” Lancet 1 (1964): 235–39. See also VA Cooperative Study Group, “Effects of Treatment on Morbidity of Hypertension,” Journal of the American Medical Association 202 (1967): 1028–33.
10“After that, survival”: R. L. McNamara et al., “Effect of Door-to-Balloon Time on Mortality in Patients with ST-Segment Elevation Myocardial Infarction,” Journal of the American College of Cardiology 47 (2006): 2180–86.
10“In 2006”: E. H. Bradley et al., “Strategies for Reducing the Door-to-Balloon Time in Acute Myocardial Infarction,” New England Journal of Medicine 355 (2006): 2308–20.
10 “Studies have found”: E. A. McGlynn et al., “Rand Research Brief: The First National Report Card on Quality of Health Care in America,” Rand Corporation, 2006.
11“You see it in the 36 percent increase”: American Bar Association, Profile of Legal Malpractice Claims, 2004–2007 (Chicago: American Bar Association, 2008).
1. THE PROBLEM OF EXTREME COMPLEXITY
15 “I read a case report”: M. Thalmann, N. Trampitsch, M. Haberfellner, et al., “Resuscitation in Near Drowning with Extracorporeal Membrane Oxygenation,” Annals of Thoracic Surgery 72 (2001): 607–8.
21“The answer that came back”: Further details of the analysis by Marcus Semel, Richard Marshall, and Amy Marston will appear in a forthcoming scientific article.
23 “On any given day”: Society of Critical Care Medicine, Critical Care Statistics in the United States, 2006.
23“The average stay”: J. E. Zimmerman et al., “Intensive Care Unit Length of Stay: Benchmarking Based on Acute Physiology and Chronic Health Evaluation (APACHE) IV,” Critical Care Medicine 34 (2006): 2517–29.
23 “Fifteen years ago”: Y. Donchin et al., “A Look into the Nature and Causes of Human Errors in the Intensive Care Unit,” Critical Care Medicine 23 (1995): 294–300.
24“There are dangers simply”: N. Vaecker et al., “Bone Resorption Is Induced on the Second Day of Bed Rest: Results of a Controlled, Crossover Trial,” Journal of Applied Physiology 95 (2003): 977–82.
28“national statistics show”: Centers for Disease Control, “National Nosocomial Infection Surveillance (NNIS) System Report, 2004, Data Summary from January 1992 through June 2004, Issued October 2004,” American Journal of Infection Control 32 (2004): 470–85.
28“Those who survive line infections”: P. Kalfon et al., “Comparison of Silver-Impregnated with Standard Multi-Lumen Central Venous Catheters in Critically Ill Patients,” Critical Care Medicine 35 (2007): 1032–39.
28 “All in all, about half”: S. Ghorra et al., “Analysis of the Effect of Conversion from Open to Closed Surgical Intensive Care Units,” Annals of Surgery 2 (1999): 163–71.
2. THE CHECKLIST
32“On October 30, 1935”: P. S. Meilinger, “When the Fortress Went Down,” Air Force Magazine, Oct. 2004, pp. 78–82.
35“A study of forty-one thousand”: J. R. Clarke, A. V. Ragone, and L. Greenwald, “Comparisons of Survival Predictions Using Survival Risk Ratios Based on International Classification of Diseases, Ninth Revision and Abbreviated Injury Scale Trauma Diagnosis Codes,” Journal of Trauma 59 (2005): 563–69.
35“Practitioners have had the means”: J. V. Stewart, Vital Signs and Resuscitation (Georgetown, TX: Landes Bioscience, 2003).
38“In more than a third of patients”: S. M. Berenholtz et al., “Eliminating Catheter-Related Bloodstream Infections in the Intensive Care Unit,” Critical Care Medicine 32 (2004): 2014– 20.
39 “This reduced from 41 percent”: M. A. Erdek and P. J. Pronovost, “Improvement of Assessment and Treatment of Pain in the Critically Ill,” International Journal for Quality Improvement in Healthcare 16 (2004): 59–64.
39 “The proportion of patients”: S. M. Berenholtz et al., “Improving Care for the Ventilated Patient,”
Joint Commission Journal on Quality and Safety 4 (2004): 195–204.
39 “The researchers found”: P. J. Pronovost et al., “Improving Communication in the ICU Using Daily Goals,” Journal of Critical Care 18 (2003): 71–75.
39 “In a survey of ICU staff”: Berenholtz et al., “Improving Care.”
41“But between 2000 and 2003”: K. Norris, “DMC Ends 2004 in the Black, but Storm Clouds Linger,” Detroit Free Press, March 30, 2005.
44“In December 2006”: P. J. Pronovost et al., “An Intervention to Reduce Catheter-Related Bloodstream Infections in the ICU,” New England Journal of Medicine 355 (2006): 2725–32.
3. THE END OF THE MASTER BUILDER
48“Two professors who study”: S. Glouberman and B. Zimmerman, “Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like?” discussion paper no. 8, Commission on the Future of Health Care in Canada, Saskatoon, 2002.
54 “His firm, McNamara/Salvia”: Portfolio at www.mcsal.com.
59“We’ve been slow to adapt”: Data from the Dartmouth Atlas of Health Care, www.darmouthatlas.org.
69 “It was planned to rise”: R. J. McNamara, “Robert J. McNamara, SE, FASCE,” Structural Design of Tall and Special Buildings 17 (2008): 493–512.
70 “But, as a New Yorker story”: Joe Morgenstern, “The Fifty-Nine-Story Crisis,” New Yorker, May 29, 1995.
71 “In the United States”: U.S. Census data for 2003 and 2008, www.census.gov; K. Wardhana and
F. C. Hadipriono, “Study of Recent Building Failures in the United States,” Journal of Performance of Constructed Facilities 17 (2003): 151–58.
4. THE IDEA
73“At 6:00 a.m.”: Hurricane Katrina events and data from E. Scott, “Hurricane Katrina,” Managing Crises: Responses to Large-Scale Emergencies, ed. A. M. Howitt and H. B. Leonard (Washington, D.C.: CQ Press, 2009), pp. 13–74.
76“Of all organizations”: Wal-Mart events and data from S. Rose -grant, “Wal-Mart’s Response to Hurricane Katrina,” Managing Crises, pp. 379–406.
78“For every Wal-Mart”: D. Gross, “What FEMA Could Learn from Wal-Mart: Less Than You Think,” Slate, Sept. 23, 2005, http://www.slate.com/id/2126832.
78 “In the early days”: Scott, “Hurricane Katrina,” p. 49.
80 “As Roth explained”: D. L. Roth, Crazy from the Heat (New York: Hyperion, 1997).
81 “Her focus is on regional Italian cuisine”: J. Adams and K. Rivard, In the Hands of a Chef: Cooking with Jody Adams of Rialto Restaurant (New York: William Morrow, 2002).
5.THE FIRST TRY
87“By 2004”: T. G. Weiser et al., “An Estimation of the Global Volume of Surgery: A Modelling Strategy Based on Available Data,” Lancet 372 (2008): 139–44.
87 “Although most of the time”: A. A. Gawande et al., “The Incidence and Nature of Surgical Adverse Events in Colorado and Utah in 1992,” Surgery 126 (1999): 66–75.
87“Worldwide, at least seven million people”: Weiser, “An Estimation,” and World Health Organization, World Health Report, 2004 (Geneva: WHO, 2004). See annex, table 2.
91“The strategy has shown results”: P. K. Lindenauer et al., “Public Reporting and Pay for Performance in Hospital Quality Improvement,” New England Journal of Medicine 356 (2007): 486–96.
93 “When the disease struck”: S. Johnson, The Ghost Map (New York: Riverhead, 2006).
95“Luby and his team reported”: S. P. Luby et al., “Effect of Hand-washing on Child Health: A Randomised Controlled Trial,” Lancet 366 (2005): 225–33.
98“But give it on time”: A. A. Gawande and T. G. Weiser, eds., World Health Organization Guidelines for Safe Surgery (Geneva: WHO, 2008).
102“In one survey of three hundred”: M. A. Makary et al., “Operating Room Briefings and Wrong- Site Surgery,” Journal of the American College of Surgeons 204 (2007): 236–43.
102 “surveyed more than a thousand”: J. B. Sexton, E. J. Thomas, and R. L. Helmsreich, “Error, Stress, and Teamwork in Medicine and Aviation,” British Medical Journal 320 (2000): 745– 49.
108 “The researchers learned”: See preliminary data reported in “Team Communication in Safety,”
OR Manager 19, no. 12 (2003): 3.
109 “After three months”: Makary et al., “Operating Room Briefings and Wrong-Site Surgery.”
109 “At the Kaiser hospitals”: “ ‘Preflight Checklist’ Builds Safety Culture, Reduces Nurse Turnover,” OR Manager 19, no. 12 (2003): 1–4.
109 “At Toronto”: L. Lingard et al. “Getting Teams to Talk: Development and Prior Implementation of a Checklist to Promote Interpersonal Communication in the OR,” Quality and Safety in Health Care 14 (2005): 340–46.
6. THE CHECKLIST FACTORY
114 “Among the articles I found”: D. J. Boorman, “Reducing Flight Crew Errors and Minimizing New Error Modes with Electronic Checklists,” Proceedings of the International Conference on Human-Computer Interaction in Aeronautics (Toulouse: Editions Cépaudès, 2000), pp. 57– 63; D. J. Boorman, “Today’s Electronic Checklists Reduce Likelihood of Crew Errors and Help Prevent Mishaps,” ICAO Journal 56 (2001): 17–20.
116“An electrical short”: National Traffic Safety Board, “Aircraft Accident Report: Explosive Decompression—Loss of Cargo Door in Flight, United Airlines Flight 811, Boeing 747-122, N4713U, Honolulu, Hawaii, February 24, 1989,” Washington D.C., March 18, 1992.
116“The plane was climbing”: S. White, “Twenty-Six Minutes of Terror,” Flight Safety Australia, Nov.–Dec. 1999, pp. 40–42.
120 “They can help experts”: A. Degani and E. L. Wiener, “Human Factors of Flight-Deck Checklists: The Normal Checklist,” NASA Contractor Report 177549, Ames Research Center, May 1990.
121“Some have been found confusing”: Aviation Safety Reporting System, “ASRS Database Report Set: Checklist Incidents,” 2009.
129“Crash investigators with Britain’s”: Air Accidents Investigation Branch, “AAIB Interim Report: Accident to Boeing 777-236ER, G-YMMM, at London Heathrow Airport on 17 January 2008,” Department of Transport, London, Sept. 2008.
129“ ‘It was just yards above’ ”: M. Fricker, “Gordon Brown Just 25 Feet from Death in Heathrow Crash,” Daily Mirror, Jan. 18, 2008.
129“The nose wheels collapsed”: Air Accidents Investigation Branch, “AAIB Bulletin S1/2008,” Department of Transport, London, Feb. 2008.
130“Their initial reports”: Air Accidents Investigation Branch, “AAIB Bulletin S1/2008”; Air Accidents Investigation Branch, “AAIB Bulletin S3/2008,” Department of Transport, London, May 2008.
132“Nonetheless, the investigators tested”: Air Accidents Investigation Branch, “AAIB Interim Report.”
132 “So in September 2008”: Federal Aviation Administration, Airworthiness Directive; Boeing Model 777-200 and -300 Series Airplanes Equipped with Rolls-Royce Model RB211-TRENT 800 Series Engines, Washington, D.C., Sept. 12, 2008.
133 “One study in medicine”: E. A. Balas and S. A. Boren, “Managing Clinical Knowledge for Health Care Improvement,” Yearbook of Medical Informatics (2000): 65–70.
133“almost 700,000 medical journal articles”: National Library of Medicine, “Key Medline Indicators,” Nov. 12, 2008, accessed at www.nlm.nih.gov/bsd/bsd_key.html.
134 “This time it was”: National Transportation Safety Board, “Safety Recommendations A-09-17- 18,” Washington, D.C., March 11, 2009.
7. THE TEST
139 “Of the tens of millions”: Joint Commission, Sentinel Event Alert, June 24, 2003.
139“By comparison, some 300,000”: R. D. Scott, “The Direct Medical Costs of Healthcare- Associated Infections in U.S. Hospitals and the Benefits of Prevention,” Centers for Disease Control, March 2009.
140“The final WHO safe surgery checklist”: The checklist can be accessed at www.who.int/safesurgery.
146“We gave them some PowerPoint slides”: The videos can be viewed at www.safesurg.org/materials.html.
156“In January 2009”: A. B. Haynes et al., “A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population,” New England Journal of Medicine 360 (2009): 491–99.
8. THE HERO IN THE AGE OF CHECKLISTS
161 “Tom Wolfe’s The Right Stuff”: T. Wolfe, The Right Stuff (New York: Farrar, Straus and Giroux, 1979).
163 “Neuroscientists have found”: H. Breiter et al., “Functional Imaging of Neural Responses to Expectancy and Experience of Monetary Gains and Losses,” Neuron 30 (2001): 619–39.
166 “ ‘Cort’s earning power’ ”: Wesco Financial Corporation, Securities and Exchange Commission, Form 8-K filing, May 4, 2005.
170 “Smart specifically studied”: G. H. Smart, “Management Assessment Methods in Venture Capital: An Empirical Analysis of Human Capital Valuation,” Journal of Private Equity 2, no. 3 (1999): 29–45.
172“He has since gone on”: G. H. Smart and R. Street, Who: The A Method for Hiring (New York: Ballantine, 2008).
173 “A National Transportation Safety Board official”: J. Olshan and I. Livingston, “Quiet Air Hero Is Captain America,” New York Post, Jan. 17, 2009.
174“As Sullenberger kept saying”: M. Phillips, “Sully, Flight 1549 Crew Receive Keys to New York City,” The Middle Seat, blog, Wall Street Journal, Feb. 9, 2009, http://blogs.wsj.com/middleseat/2009/02/09/.
174 “ ‘That was so long ago’ ”: “Sully’s Tale,” Air & Space, Feb. 18, 2009.
178“Once that happened”: C. Sullenberger and J. Zaslow, Highest Duty: My Search for What Really Matters (New York: William Morrow, 2009).
179“Skiles managed to complete”: Testimony of Captain Terry Lutz, Experimental Test pilot, Engineering Flight Operations, Airbus, National Transportation Safety Board, “Public Hearing in the Matter of the Landing of US Air Flight 1549 in the Hudson River, Weehawken, New Jersey, January 15, 2009,” June 10, 2009.
180“ ‘Flaps out?’ ”: D. P. Brazy, “Group Chairman’s Factual Report of Investigation: Cockpit Voice Recorder DCA09MA026,” National Transportation Safety Board, April 22, 2009.
180 “For, as journalist and pilot”: W. Langewiesche, “Anatomy of a Miracle,” Vanity Fair, June 2009.
181 “After the plane landed”: Testimony of Captain Chesley Sullenberger, A320 Captain, US Airways, National Transportation Safety Board, Public Hearing, June 9, 2009.
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