The Checklist Manifesto – How To Get Things Right by Atul Gawande – New York: Picador, 2011

How could a book about checklists be all that interesting? Trust me on this one. You will be riveted. I read this book, the first time, straight through without stopping. For families and individuals who have any type of medical issues that require close interaction with the medical establishment, this book is a basic safety preparedness course. Gawande spells out, in almost horrifying detail, the number of errors that occur in surgery, not just in distant countries with lower standards of medicine, but weekly, even daily, in our major teaching hospitals. Before you or a loved one goes under the knife, ask your doctor whether surgical checklists are in common use.

The month-to-month interaction of a therapist with the family of a child with cerebral palsy is not very dramatic when compared to open-heart surgery. However, the routine nature of treatment for a chronic condition may lead to errors and omissions in a management plan that stretches over years. I am a strong advocate of parents developing and individuals maintaining, their own personal checklists of Key Tasks related to their care. I prefer a checklist to a goal list. The problem with goals is that we so often fail to reach them. When the same list is presented as a checklist, I have found that I am much more likely to use it. The checklist becomes part of my routine.

Let me give an example of a common problem in pediatric neurorehabilitation that could be easily avoided with the use of a checklist. Limitation of movement and joint contracture are distressingly common problems in children with Cerebral Palsy or Brachial Plexus Injury. The trouble often starts as they move through growth spurts. The question to ask is, “How often does your therapist or physician check the range of motion in the affected joints?” In a growing child, this examination should take place every 3 to 6 months as a minimum and anytime you report a growth spurt. Measurement without documentation and analysis is next to useless. The second question is, “Do they write down the result of their examination and compare it to their previous findings?” Unless each measurement is systematically gathered and compared over time, small changes tend to be ignored. Eventually there will be enough change that the downward trending will be noticed. Once there is a significant degree of tightness, more intensive interventions, such as serial casting, Botulinum injections and/or surgery will be needed to correct the problem. In my opinion, the earlier you diagnose a negative change, the earlier the problem can be treated. We all know that dealing with the problem when it is a small one is better than waiting until a full blown problem stares you in the face.

Gawande put it best, “First think about what happens in most lines of professional work when a major failure occurs. To begin with, we rarely investigate our failures. Not in medicine, not in teaching, not in the legal profession, not in the financial world, not in virtually any other kind of work where the mistakes do not turn up on cable news. A single type of error can affect thousands, but because it usually touches only one person at a time, we tend not to search as hard for explanations. Sometimes, though, failures are investigated. We learn better ways of doing things.” (Page 132-133) And one of those better ways of doing things is to create a checklist to make sure important procedures and tests are not forgotten or skipped. When you read Gawande’s book, I’m sure you will come up with many more items that you would like to put on your personal checklist for your rehabilitation program.

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