In 1935, a new Boeing plane took off, stalled and crashed. The report into the accident said it was due to pilot error as the pilot had forgotten to undo a lock that stopped the rudder from moving correctly. As a result of this the aviation industry brought in checklists to ensure that no matter how skilled or expert a pilot was they would not forget to do the simple, life-saving steps necessary to fly a plane safely.
Medicine has been slow to embrace this concept but the WHO introduced a surgical safety checklist in 2009 making sure that surgeons confirmed some simple steps such as the correct patient and operative site, details of any critical or potentially complex steps, potential blood loss, need for antibiotics etc. A ground-breaking study published in the NEJM in a trial of over 3,700 operations around the world showed a drop in mortality from 1.5% to 0.7% and a similar drop in complications.
Today's presentation highlighted this and was also an opportunity to introduce a new, clearer and hopefully more effective checklist that I have been working on that we aim to introduce in the next few months.