Errors, Knowledge, and Quality Assurance

In his book The Checklist Manifesto, which is an expansion of “The Checklist” published in The New Yorker, Gawande marvelously describes how simple, well-designed checklists can help prevent and solve extraordinarily complex problems and thereby improve patient outcomes in medicine. Gawande begins by distinguishing between “necessary fallibility,” the idea that, even when enhanced by technology, we (physicians) fail because what we set out to do is beyond our physical and mental capacities, failure due to ignorance, the idea that we “err because science has given us only a partial understanding of the world and how it works” (i.e. lack of knowledge), and failure due to ineptitude, the idea that we err because even though “the knowledge exists, …we fail to apply it correctly” (7-8). Up until the last several decades, many of the errors we made in medicine were due to sheer ignorance; however, since then, we have gained enough scientific knowledge such that errors due to ineptitude are becoming as much our struggle as errors due to ignorance. While error due to ignorance may be easily forgivable, error due to ineptitude is not and Gawande presents a simple manner – checklists – that have the power to improve the safety and quality of patient care. These checklists are based around regimentation in the sense that they ensure that a multitude of steps are carried out in a specific sequence and manner. Gawande writes of how such simple measures - checklists, regimentation, and ensuring that gaps are filled – utilize the medical knowledge we do have effectively. These measures have resulted in greater hand hygiene thus lowering the spread of infections in hospitals, the widespread deliverance of the polio vaccine in polio-stricken areas, reduction of infection resulting from central line insertion, and reduction of major surgical complications as Gawande details in Better and “The Checklist.” When the knowledge now exists to improve the safety and quality of medical care, it seems marvelous that it is resulting in better patient outcomes, but also ridiculous that rates of hand hygiene, infection, surgical complication, etc are still nowhere near 0%. There is thus always room for improvement.