John Murtha surgeon's error: was a checklist in use?

It is not just that we should be asking in the matter of the accidental death of PA Democratic Rep John Murtha whether a surgical assistant was present, but whether a checklist was in use at each critical stage of the procedure.


The failure to use a checklist can result in the surgical equivalent of an experienced and capable pilot landing an aircraft with the landing gear still up.


Aviation has had to learn some hard lessons about Cockpit (crew) Resource Management.  Other disciplines have been inspired to change by authors invoking the metaphor of "the surgical team" and "the operation".


The day is gone when any successful aircraft landing is one fro which you can walk away.  The day is gone of the successful operation (but patient died) as was the case of early "artificial heart" recipients too weak to survive major thoracic surgery.


Accidental nicks to the GI tract resulting in potentially fatal peritonitis are a surgical common-place.  So were various anaesthesia errors prior to the reform of equipment and procedure (reversing compatible gas line connections being notorious pre-op errors.)


The recent attention to Atul Gawande's "The Checklist Manifesto: How to Get Things Right" by Jon Stewart may be enough to ensure that someone will ask: was the lead surgeon following a checklist when that blade nicked the colon.


Those of us who are old enough to remember the Mayo Clinic as the place to get a gall bladder removed will know that there is no peritoneal surgery - even laparoscopic - without risk.  And there is no landing an aircraft without risk.  But risk can be reduced if the big ego is not in the way.  So what went wrong?


Did the nick occur due to the failure to correctly configure a surgical tool prior to retraction or repositioning?  If a checklist was not in use and if this was surgeon error, could a checklist have helped to prevent that error?