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Comment by michaelt | Hacker News Reader

And here is the checklist [1]

These seem like very common-sense things to check - Is this the right patient? Are the instruments sterile? Have we counted all the surgical equipment after the procedure?

[1] https://apps.who.int/iris/bitstream/handle/10665/44186/97892...

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Maybe so. When was the last time you forgot to do something that was "common-sense"? Forgot to pick up your coat after work? Left your wallet on your desk? Now imagine each of those mistakes was fatal for a patient.

The issue is in the margins.

Maybe a shift-change caused the surgical team to be different from normal, so people aren't as comfortable with each other. There's social/professional pressure to fit within a hierarchy, especially with new people. Maybe a few people lower on the totem pole think something might be off, but don't want to say anything lest they risk appearing to undermine the surgeon.

So, at first it appears that a whole room of people would need to independently make the same mistake. But that's not so; only a few critical people need to make the mistake, and with enough ambiguity in the process (easily caused by anything happening 'out of the ordinary'), it won't be corrected some percentage of the time. Even seemingly trivial things.

The FAA found this occurring in the cockpit, especially from the '3rd seat'. A pilot and first officer may be 'in the weeds' dealing with the immediate threat of a situation, whereas others have the benefit of distance to reflect on a situation and observe more clearly. They don't get tunnel vision, and are in a better place to diagnose a tricky problem. However, they may not feel empowered to speak up, or feel they don't have the information the pilots do. Aviation has, broadly, sought to correct this and encourage anyone to speak up. Recently, this happened during the flight before the Indonesia 737 crash where similar AoA/MCAS issues occurred, but a 3rd pilot helped to address the situation.

It's always worth remembering that "after" can be after 10+ hours of continuous high-stress concentration, so remembering lots of little things can be very challenging.

Thanks, I can't believe this wasn't in article. The BBC might need a checklist of their own.

1. If the article is referencing a document, video, or picture, is it linked/embedded?

[ ] Yes [ ] Not available [ ] Not applicable

2. If the document refers to a third party report, is it linked?

[ ] Yes [ ] Not available online [ ] Not applicable

3. Are background sources linked to high-quality, external sources?

[ ] At least 3 links present [ ] We sat there for 1 minute and couldn't come up with anything that needs linking

4. Are needless generic internal links to category/tag pages etc. removed?

[ ] Yes

This is pretty interesting.

There seems to be a whole other list referenced: "Is the anaesthesia machine and medication check complete?"

Also the team are supposed to intro themselves along with their roles. I wonder if it often happens that someone is missing?

I'd bet more often it's two people who could each do the other's role and therefore wanting to be specific that one person is responsible for X and the other Y.

That's the sign of a good checklist. The idea is to free up mental processing to focus on harder issues. Let the doctor focus on the hard stuff and not spend excess time trying to remember the simple stuff.

As a life long patient, while I appreciate the checklists, I think some of the repeated rechecking is a bit much.

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