Preventing Brain Surgery Errors… Not Exactly Rocket Science


Thanks to those of you who sent me the link to this Washington Post article called “The Pain of Wrong Site Surgery.” The piece highlights how the patient safety battle has not yet been won and “some researchers and patient safety experts say the problem of wrong-site surgery has not improved and may be getting worse.” A recent Health Affairs study found that medical errors affected one-third of hospital patients.

Why is it so hard to use checklists in the right culture (a “just culture,” perhaps) that makes so-called “never events,” such as wrong-site surgeries never happen? People might say “it's not rocket science” to follow basic procedural steps.

“I'd argue that this really is rocket science,” said [Dr.] Mark Chassin, a former New York state health commissioner and since 2008 president of the Joint Commission.

But is it?

Some of the other quoted doctors express frustration that medical errors haven't been eliminated, including one who differs with Dr. Chassin:

“This is not quite ‘Dick and Jane,' but it's pretty close,” surgeon Dennis O'Leary declared in a 2004 interview about the “universal protocol” to prevent wrong-site surgery. These rules require preoperative verification of important details, marking of the surgical site and a timeout to confirm everything just before the procedure starts.

Dr. O'Leary added this is “very simple stuff.”

Dr. Peter Pronovost, author of the excellent book Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out, says:

“It's disheartening that we haven't moved the needle on this,” said Peter Pronovost, a prominent safety expert and medical director of the Johns Hopkins Center for Innovation in Quality Patient Care. “I think we made national policy with a relatively superficial understanding of the problem.” Pronovost suggests that doctors' lip service to the rules, which he calls “ritualized compliance,” may be a key factor. Studies of wrong-site errors have consistently revealed a failure by physicians to participate in a timeout.

As I've been trying to help teach for years – it's not the checklist itself that's important, it's how it's used – it's about having the right culture and accountability in place. Having a laminated checklist does no good if a surgeon won't follow it, if they're pressured for time or productivity and feel that they can't use it, or if nurses, techs, and other staff members can't speak up when they see somebody ignoring the timeout, checklist, or “universal protocol,” whatever you'd like to call it. The checklist can't help patients if medical professionals aren't using the checklist.

“Universal protocol” certainly was an aspirational statement. It seems to not be reality today, the “universal” aspect.

Another comment from the article:

“It's very frustrating,” said surgeon John Clarke, clinical director of the Pennsylvania Patient Safety Authority. “If you can't solve the wrong-site-surgery problem, what can you solve?”


Why is this so hard?

Dr. Chassin said:

Preventing wrong-site surgery also “turns out to be more complicated to eradicate than anybody thought,” he said, because it involves changing the culture of hospitals and getting doctors — who typically prize their autonomy, resist checklists and underestimate their propensity for error — to follow standardized procedures and work in teams.

Changing the culture requires leadership and it might be challenging, but it's not rocket science. It's psychology, if anything.

My friend Naida Grunden sent me another story, “Nudging Doctors In Intensive Care Unit Reduces Deaths.

From that Northwestern research:

A new Northwestern Medicine study shows the attending physician in the intensive care unit could use a copilot, too. The mortality rate plummeted 50 percent when the attending physician in the intensive care unit had a checklist – a fairly new concept in medicine — and a trusted person prompting him to address issues on the checklist if they were being overlooked. Simply using a checklist alone did not produce an improvement in mortality.

It's not the checklist, it's how you use it. I'd argue this is NOT rocket science. Again, it's complicated to think about WHO is going to prompt the surgeon and what the implications are of power and hierarchy in the O.R. One reason aviation safety has been so improved, through their more effective use of checklists is the cultural shift to reduce hierarchies in the cockpit so that the first officer feels safer speaking up to the captain if they think there is a problem.

This is all a pretty meaty and serious topic. Please read the entire WashPo piece (there are multiple pages if you don't have it in print-ready mode). Please share your thoughts and reactions here in the comments.

To try to go into the weekend on somewhat of a light note, here is a video that was first shared with me a few weeks ago when I was doing a Lean healthcare workshop. I hope you have access to the video or go watch it over the weekend. It's a good laugh…. an arrogant brain surgeon introducing himself at a party to people. The punch line is pretty obvious, but it's still brilliantly delivered at the end.

Have a good weekend.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Great post, Mark. I think the problem may be that Pronovost, Gawande, et al did underestimate what it would take to make the running of checklists routine. A checklist is simple. So is a kanban card. But the system of attitudes, beliefs and procedures that underlie each one has to be in place before the artifact will be useful. A checklist is not as simple as a grocery list, but requires a lot of thought to design. Yes, it is all about culture change, including the reduction of physician autonomy and the work environment where every person is not merely “empowered” but “expected” to call out irregularities.
    I asked my husband (retired captain) what would happen if they tried to start a flight without doing, say, a pre-takeoff checklist. He told me that other crew members would speak up, probably like barking dogs, and if an FAA examiner were in the cockpit, s/he would turn you around and send you back to the terminal, and they’d be in Big Trouble.
    Getting from where we are now–doctors STILL don’t think it matters–to where we need to be–doctors, like pilots, unable to imagine NOT using a checklist–will involve leadership. (Where have we heard that before?) That means JCAHO will have to stop calling the running of checklists “rocket science” and start leading the change!
    And thanks for the video, Mark. It’s classic!

  2. Funny video. I have two physician-astronaut colleagues who both use this same idea in their speaking engagements.

    I respectfully disagree with you Mark. Checklists are rocket science. That’s why every time NASA launches a rocket, or refits a shuttle, or runs an experiment on the space station, etc., they use a checklist. One of Hoot Gibson’s immutable “Hoot’s Laws” is, “We always follow the checklist.”

    Further, much of the heavy lifting surrounding the culture change that Naida’s husband (and all the rest of us who fly airplanes professionally) experienced was based on research carried out by…. wait for it…. NASA.

    I think we too often confuse “simple” with “easy”. For example, jumping over the Empire State Building is simple. Run towards the building, make a great leap, clear the top of the building, and safely land on the other side. Four simple steps. I’m comfortable asserting that it’s not easy, at least not for me.

    Any standardized work, including checklists, is simple. The culture change around it, which we all agree is essential, is where “easy” becomes uneasy.

    Culture change is complex, is difficult, requires persistence. It’s not impossible however. Continuous innovation and refinement of known best practices in culture change is what gets me out of bed in the morning. Cool stuff, and thanks for this piece. Have a great weekend my friend.

    • Thanks for your insightful comments, both of you, Naida and Monty.

      Steve – I appreciate that checklists are a major part of rocket science and aviation. I guess by “rocket science” I mean the science, math, computers, and technology required to land men on the moon and return them safely. That’s more a parallel to figuring out how to do brain surgery from a clinical/technical standpoint.

      Great point on “simple vs easy.”

  3. Yes, maybe it IS rocket science! Maybe Steve has it exactly right! I think the term is used ironically in the quote in this article to mean, “impossible.” Rocket science is not impossible: it’s hard. It’s not time to throw up our hands in grudging acceptance of the status quo, but rather, time to dig in and persuade the medical community to apply … rocket science.

    • We’re all in rabid agreement that things need to improve and that people can’t expect solutions that don’t require any effort. The effective use of checklists and the required change are difficult. They are often difficult, perhaps, because we don’t have leaders who are willing to stand up to really lead their organizations. I wonder how many CEOs try to just delegate checklists (and responsibility for using them the right way) or hire a consultant who is “doing that for them”?

      That lack of leadership makes this much harder than it should be?

  4. Here is a very sad story about the human impact of medical errors on the surgeons and providers.

    Surgeon ‘hanged himself after operation error’

    A top surgeon who hanged himself at his country home had been “plagued with guilt” after making an error during an operation, it was claimed last night.


    How can we create an environment where people can get the proper counseling and support for when a mistake occurs?

  5. Another root cause from the article: “underestimate their propensity for error”?

    Apart from the medical undergrads in this country getting very full of themselves (having scored top marks in the high school exams) – how can you teach people who are accustomed to not making mistakes – which is true since in my state you need to get about 159 out 160 in your final year – that they will very much be making mistakes, whether they like it or not.

    Should you run special tests or simulations where they can’t possibly get it right, in order to learn the concept of error and failure?

    I’m not joking, in our country anyway we are talking about young medical undegrads who probably haven’t made any mistakes in school tests or exams since they were 12.

  6. Mark,

    My wife says that at her hospital, it’s very common for nurses to voice disagreement with physicians in the procedure room. She thinks that’s because the nurses are in a separate reporting structure — their boss is the nurse supervisor, not the physician — and that provides them with political (and emotional) protection. Not sure if that’s the case in other institutions.

    • Dan, I think that’s not at all unusual to be in different reporting structures. I think there’s something good culturally there in your wife’s hospital. Good leadership or maybe especially joint leadership from medical and administrative sides of things?

  7. Fine post Mark — thanks, as ever.

    What kind of thinking — or “mental models” — underlie wrong site surgeries & other catastrophic medical errors?

    Here’s a common health care mental model:

    “We worship at the altar of technology — (not management…)”

    Worshiping complex machines, as well as, “brain surgeons” and other specialists are all expressions of same.

    NASA (and most other high-risk industries), as Steve points out, have learned the hard way to “always follow the checklist” — a tip of the hat to the art of management.

    “Following the checklist” expresses management fundamentals:
    a) we know what’s most important,
    b) we summarize it in an easy to use checklist,
    c) we train our people in what’s most important,
    d) we check to ensure they can actual DO what’s most important, and so on.

    A “simple” checklist used correctly sits atop a management system.

    Therein lies the remedy to our health care travails — a steep climb, but we have no choice.

  8. If patients considered “uses a checklist” as one of the criteria for choosing a surgeon/hospital, there would be more pressure to change. We don’t always realize, especially when faced with something as scary as surgery, that hospitals are competing viciously for dollars. In fact, should there be a “patient’s checklist” as well? In the meantime, my poka-yoke has been to make big arrows with magic marker on my body before surgery to point to the right site.

    • Has anybody successfully used that tactic, asking the surgeon or the hospital “do you effectively use checklists?” or “please describe your thoughts on the team environment and non-hierarchical structures in the O.R.?”

      We so often talk about clinical things (and people are often afraid to challenge their surgeon on “is this the right procedure?”)… are people having these sorts of process-related discussions?

      Good luck finding data — which surgery centers have lower infection rates, etc… isn’t that data notoriously hard to get, to be able to make an informed decision as a patient?

  9. Well I can tell you that at least one author has advocated this kind of consumer-driven activism. Yes, the government can drive quality initiatives through CMS, but if patients can vote with their feet then you’ll begin to have hospital CFO’s driving quality initiatives. The key to that vision is “can”. Many patients can’t vote with their feet because of insurance, access to transportation, lack of $$, lack of knowledge, etc.

    So when it comes to lack of knowledge, we come back to where I started. Disclaimer, the author of “Never Go to the Hospital Alone” is my friend and the founder of LifeWings Partners, LLC. Still, here’s his book:


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