Wednesday, October 1, 2014

Public Health and the Secret Service both need better checklists

The Liberian public health and airport security personnel in Liberia did their jobs, and checked outgoing passengers at three distinct checkpoints.  We've patted ourselves on the back in this country for the sophistication of our medical capabilities, yet as I listened to the story today of the nurse in Dallas who followed a "checklist" and got a Big Red Flag answer back from the patient, but failed to escalate it in such a way that the team could isolate and contain the patient -- in fact, they sent him away with antibiotics and he came back a second time when he felt worse -- I thought once again of Dr. Atul Gawande's book, The Checklist Manifesto

This type of error is called one of ineptitude, as opposed to one of ignorance, presumably.  We don't know if this was an Ebola-specific checklist; one prepared by the hospital itself; or one from the Center for Disease Controls.  A quick read of Gawande's book might be very helpful, especially if the checklist has more than 5-7 items on it, without what Gawande calls "pause points."  His book is full of stories of how pilots, builders of skyscrapers and surgical teams perform extremely complicated feats, and how using checklists that involve every member of the team makes a difference.  His work in this respect for the World Health Organization has made a large impact:  deaths after surgeries have been reduced significantly by the implementation of several simple procedures that are part of the checklist.

I would also recommend the book to the new acting director of the Secret Service and to the panel that is currently being constituted to review the disturbing procedural/process failures over the last several years for the organization charged with guarding the president.  It may be that those procedures or processes have become shopworn.  Certainly it must be the case that, unless on a form of high alert (the United Nations responsibility, for example) agents' situational awareness is at an all time low.  Whether this is a factor related to the move from Treasury to the Department of Homeland Security or not is difficult to estimate, but will undoubtedly be reviewed by the panel.

The tipping point I mentioned last week seems more vivid as weeks go by.  Yet there was one piece of good news this morning:  that it appears Nigeria, the most populous and also most well-off African country in terms of infrastructure and medical personnel, has contained Ebola.  We just can't move quickly enough to get more personnel, hospitals, emergency operations centers and supplies deployed in the remaining countries. 

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