In health care, little details make all the difference

When I heard in October that Superstorm Sandy was projected to make landfall somewhere in the vicinity of DC and Maryland, I prepared for the worst. I stocked up on non-perishable goods and evacuated to higher ground. (The rest of my family was already coincidentally out of town and harm's way.) I put fresh batteries into two flashlights and installed a flashlight app on my smartphone for good measure. Although I didn't give it much thought at the time, I assumed that hospitals in Sandy's path were taking similar precautions - stocking medical supplies, testing backup generators and so forth. So when a power failure at NYU Langone Medical Center forced an evacuation of the entire hospital, with heart-stopping scenes of neonatal ICU nurses cradling respirator-dependent newborns down several flights of stairs to safety, I couldn't understand what had happened. How had they not been better prepared? Had NYU administrators been the equivalent of residents of low-lying coastal areas who ignored repeated warnings and defied evacuation orders?


As it turned out, NYU did a lot of things right before the storm. According to an article in ProPublica, after the scare of last year's Hurricane Irene, the hospital moved its emergency generators from street level to the rooftop and thoroughly waterproofed the generators' fuel pumps. Unfortunately, they neglected to relocate or protect the electricity distribution circuits, which remained in the basement and were quickly disabled by the flooding. As in many areas of health care, doing everything "almost right" wasn't good enough.

All people are fallible, and health professionals no less so than others. But medicine is usually less forgiving of simple mistakes. A technically perfect surgery is a disaster because it was performed on the wrong body part. A patient develops a life-threatening infection because a doctor forgot to wash his hands. A child dies three days after being discharged from an emergency room because his parents were not notified of critical lab values that came back hours after they left.

People are fallible, but health systems need not be. Despite the staggering complexity involved in flying passenger jets and constructing skyscrapers, commercial airline accidents are rare and building collapses even rarer. Atul Gawande argues in The Checklist Manifesto that checklists are the best way to make sure that small but critical details of health care are addressed systematically, so that every member of a care team feels empowered to preempt potential disasters. I believe that checklists and decision support tools are applicable not only to surgery or intensive care settings, but to primary care as well.

Fortunately, the emergency evacuation of NYU Langone Medical Center went off smoothly, and none of the patients who were transferred seem to have suffered as a result. But the good outcome of this near-miss and the low likelihood of another Sandy in the near future should not make anyone at NYU - or in any hospital or health system, for that matter - complacent about addressing the little details and vulnerabilities of health care that make all the difference.