The Checklist Manifesto Groundbreaking Approach to Mastering Complexity and Achieving Success

In “The Checklist Manifesto: How to Get Things Right,” renowned surgeon and writer Atul Gawande brilliantly explores the transformative power of checklists in tackling complex problems across various fields.

This game-changing book offers a compelling argument for the adoption of checklists as a simple yet highly effective tool to minimize errors and optimize performance.

Keep reading to discover how checklists can revolutionize your approach to problem-solving and decision-making, leading to improved outcomes and increased success in your personal and professional life.

Genres

Productivity, Career Success, Business Self Help, Medicine, Medical, Science, Psychology, Personal Development, Management, Family Practice Medicine, Hospital Administration, Time Management, Non-fiction, Decision-making

In “The Checklist Manifesto,” Atul Gawande presents a persuasive case for the use of checklists to manage complexity and reduce errors in various domains, including medicine, aviation, construction, and investing.

Drawing on his own experiences as a surgeon and extensive research, Gawande demonstrates how checklists can serve as a powerful tool to ensure consistency, precision, and safety in the face of increasingly intricate systems and processes.

The book explores the history and science behind checklists, highlighting their successful application in fields such as aviation and construction. Gawande argues that as the complexity of our knowledge and technologies grows, our ability to deliver consistent results diminishes.

Checklists offer a solution by providing a systematic approach to managing this complexity, ensuring that crucial steps are not overlooked and that best practices are followed.

Through engaging stories and real-world examples, Gawande illustrates how checklists have saved lives, prevented disasters, and improved outcomes in various settings. He emphasizes the importance of creating well-designed checklists that are concise, practical, and easy to use, while also fostering a culture of teamwork and communication.

Review

“The Checklist Manifesto” is a groundbreaking and eye-opening book that challenges conventional wisdom about problem-solving and decision-making. Atul Gawande’s clear and engaging writing style makes complex ideas accessible to a wide audience, while his expertise as a surgeon and researcher lends credibility to his arguments.

The book’s greatest strength lies in its ability to demonstrate the universal applicability of checklists across diverse fields and situations. Gawande’s examples are compelling and memorable, ranging from the dramatic story of a plane crash averted by following a checklist to the lifesaving impact of a surgical safety checklist in hospitals worldwide.

However, some readers may find that the book’s focus on checklists as a panacea for complex problems oversimplifies the challenges faced in certain domains. While checklists are undeniably valuable, they may not always be sufficient to address the most intricate and nuanced issues.

Despite this minor reservation, “The Checklist Manifesto” remains an essential read for anyone seeking to improve their performance, reduce errors, and manage complexity in their personal or professional life. The book’s insights and practical recommendations have the potential to transform the way individuals and organizations approach problem-solving and decision-making, making it a must-read for leaders, managers, and professionals across all fields.

“(T)he volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably.” – Atul Gawande, MD

Each day we process an overwhelming amount of information and take on more responsibility. As the complexity of our life increases, we make small consequential oversights in our work, despite having experience and training. These oversights cause our co-workers, managers, and customers to doubt the quality of our work.

When author and surgeon Atul Gawande makes a small oversight, like forgetting to wash his hands before surgery, he puts a patient’s life in jeopardy. According to research, these small avoidable oversights occur more than 75,000 times a year in operating rooms across America. On Gawande’s quest to find a solution he discovered a surprisingly simple, yet powerful tool the aviation industry has used for years: the checklist.

“Four generations after the first aviation checklists went into use, a lesson is emerging: checklists seem able to defend anyone, even the experienced, against failure in many more tasks than we realized. They provide a kind of cognitive net. They catch mental flaws inherent in all of us—flaws of memory and attention and thoroughness. And because they do, they raise wide, unexpected possibilities.” – Atul Gawande, MD

Recommendation

Some of the most highly trained and respected professionals in the world rely on the humble checklist to keep them organized and out of trouble. Tremendous advances in scientific knowledge now overwhelm practitioners in many fields – to the point that they make regular but frequently avoidable mistakes. Boston-based surgeon Atul Gawande chronicles how his research into the aviation, construction and investment industries helped shape the World Health Organization’s production of a two-minute, 19-point surgical checklist that has saved countless lives worldwide. While not designed to be a how-to manual, Gawande’s book provides sample checklists, instructive examples and plenty of food for thought about how to create and fine-tune checklists that fit your job and your organization’s mission. We prescribe this eye-opening report to anyone responsible for complex tasks or for the lives of others and particularly to readers who plan to check into a hospital anytime soon.

Take-Aways

• Two factors explain human error: “ignorance and ineptitude.”
• Ignorance exists because people still have a lot to learn about the world and how it works. Ineptitude occurs when knowledge exists but people don’t apply it correctly.
• Science has given professionals capabilities beyond their abilities to use them effectively.
• Many professional fields “have become too much airplane for one person to fly.”
• The aviation industry learned as early as 1935 that flying modern airplanes requires diligent use of specific checklists outlining even mundane procedures.
• The demise of the “Master Builder” led architects, engineers and contractors to create highly sophisticated systems of written checklists and communication standards.
• The pressure of making fast life-or-death decisions plagues medical professionals.
• “Getting the steps right” in many medical procedures is “brutally hard,” even for highly trained specialists.
• One oversight can prove fatal to a patient.
• In early 2009, the World Health Organization developed a two-minute, 19-point checklist that has since prevented countless surgical complications and deaths.
• Professionals must set aside their egos, accept human fallibility and use their checklists.

Introduction

Drawing from his experience as a general surgeon, Atul Gawande’s The Checklist Manifesto (2009) reveals startling evidence on how using a simple checklist can significantly reduce human error in complex professions such as aviation, engineering and medicine.

Imagine being treated for a heart attack in the 1950s. Medical knowledge of what caused heart problems was so sparse back then that you’d simply be prescribed pain relief and bed rest. Oh, and if you wanted to puff on those cigarettes during your recovery, that was fine too.

Fortunately, human knowledge has greatly expanded since then. As little as 60 years ago, doctors were fairly clueless about treating heart attacks, whereas today we have numerous methods of doing so, including blood pressure medications, cardiac catheters and even open-heart surgery. We also have a whole host of ways to prevent heart problems in the first place, from cholesterol-lowering drugs to increased exercise.

However, in complex areas like medicine, our broad knowledge base has become a double-edged sword. According to the World Health Organization, we have now defined over 13,000 syndromes, diseases and injuries. Add to that the thousands of drugs and procedures available to treat patients and we see that no one doctor or medical team can possibly master all the medical knowledge we have accumulated.

This leaves us with a problem of ineptitude. That is, we are struggling to consistently remember, organize and apply the right knowledge in the right way. Surgeons and nurses alike are under immense pressure to master the latest medical technology, deal with multiple patients at once, and carry out the vast number of steps needed to perform complicated medical procedures with precision. As they are doing this, they must simultaneously cope with the unexpected reactions and outcomes that occur when dealing with sick people.

Clearly a new kind of tool is needed if we are to make use of our vast medical knowledge and avoid potentially fatal human errors.

Progress in human understanding has become increasingly complex and overwhelming.

Checklists = Excellent Results

Several industries use checklists to verify their work and make important decisions:

• More than 16 disciplines use checklists on a major construction site to coordinate efforts and verify each major step of the building process. Their discipline to use checklists has kept the building failure rate in America to 0.00002% (1 in every 50,000 structure partially or entirely collapses due to human error).
• Venture capitalists who take a methodical, checklist-driven approach to investing in businesses are 40% less likely to fire senior management for incompetence. Venture capitalists who use checklists to verify investments experience 45% larger returns than venture capitalists who avoid using checklists to verify their decisions (on average).
• When surgeons and nurses started using checklists before surgery, major complications dropped by 36 percent, and deaths reduced by 47 percent!

Resistance to Checklists

It’s one thing to realize that checklists work, it’s another thing to actually use them.

“It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us—those we aspire to be—handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists…Maybe our idea of heroism needs updating.” – Atul Gawande, MD

To overcome the resistance of using checklists, you’ll need to make checklists efficient and effective. The more efficient a checklist is, the more likely you’ll use it. The more effective a checklist is, the more mistakes you’ll catch and the more you’ll learn to rely on it.

A Checklist for Making Useful Checklists

Pause Point

Every checklist must have a clear trigger – a location or routine action that reminds you to pause and complete the checklist. For example, I use a checklist when releasing a video on YouTube to verify the video’s description, tags, and the links within the video. The pause point is just before I hit the ‘publish’ button on YouTube.com.

Speedy

Aviation checklist specialist Dan Boorman recommends making each checklist less than 60 seconds to complete – any longer and you’ll start taking shortcuts. To make a checklist speedy, aim for 5-9 ‘killer’ items. A ‘killer’ item is an item that if missed gives the impression of poor quality, or adversely effects other people.

Short and Concise Items

A checklist is NOT a how-to guide. Each item on a checklist should be a short and concise reminder of a routine that you are familiar with (prior training and expertise). For example, a pre-surgery checklist includes: “verify reserve blood.” This item description is sufficient for surgeons since surgeons know exactly where the reserve blood is stored, and how much reserve blood is needed before starting surgery.

Field Tested and Revised

Checklists must be practical and based on actual experience. A useful checklist is made up of past failures and lessons learned. For checklists to remain useful you need to continually update the items with the latest discoveries and lessons learned.

Final note: For checklists to be effective you need to read, verify and physically check-off or click each item on a checklist. It’s the deliberate act of going through each item that makes checklists effective, NOT the fact that you are familiar with every item on a checklist.

“(Checklists) not only offer the possibility of verification but also instill a kind of discipline of higher performance.” – Atul Gawande, MD

Checklists help prevent serious but easily avoidable mistakes.

An operating theater team in San Francisco met with dire circumstances when treating a man for what they thought was a shallow stab wound. It was only after a surgeon’s incision, when the patient started spilling out copious amounts of blood, that they noticed the wound measured a foot long. It was, in fact, a bayonet injury the man had received at a Halloween costume party. Unfortunately, before the surgery, none of the medical staff had remembered to ask what kind weapon was used.

The man survived the injury; however, mistakes and misinformation in medicine happen with scary regularity and can result in serious complications or deaths. In the United States, over fifty million surgeries are performed per year, and more than 150,000 of these patients die after their surgery. According to studies, around half of these complications and deaths are avoidable.

So how can we reduce the number of mistakes being made?

Rather than spending millions on the latest medical technology, the answer is much simpler: use a checklist.

Checklists are as simple as they sound: a list of steps to be completed when carrying out a procedure. Surprisingly, it is the obvious steps – stuff that everyone should know – that are often most crucial and yet forgotten or skipped. The checklist functions as a safety net to make sure we catch the obvious stuff, such as asking, “What kind of weapon was used?” before we proceed any further. Once the basic stuff is checked off, we are mentally better equipped to tackle the more complex or unpredictable issues that are unique to each patient.

If a checklist had been used in the above bayonet injury case, the medical team would have been better prepared for any nasty, bloody surprises.

Checklists help prevent serious but easily avoidable mistakes.

Checklists should be as short as possible, include all essential steps and leave no room for misunderstandings.

It’s easy to scoff at checklists, particularly as many of us think of them as scrawled reminders or glorified to-do lists. However, when they contain all essential items, and are concise and usable, checklists become powerful tools.

One essential aspect of a checklist is that it contains the “killer items” of the procedure. These are the steps that are easily disregarded but, if not completed, could be disastrous. For example, this could be a reminder to identify a patient’s allergies before surgery.

Although they should contain all essential items, checklists should not be thorough guides. Daniel Boorman, a veteran pilot who creates aviation checklists for Boeing, says that around five to nine items are ideal, and there should be a time limit on how long it takes to go through the list. After around one minute of reading a list, people can become distracted and skip vital steps.

A checklist should also be user friendly. When implementing an early version of his checklist, the author-and-surgeon Atul Gawande confused a nurse in his team right before a surgical procedure because it was unclear how the checklist should be used. The nurse had checked off the steps for the procedure before it had even started, rather than – as Gawande had intended – reading out each step to the surgical team and checking them off as they went.

To avoid confusion, it should be clear whether the list is a “READ–DO” (read out the step, then complete it) or a “DO–CONFIRM” (complete the step, then confirm you have completed it). Lists should also be written in the language users are familiar with; for example, “fire mushrooms” (meaning “cook the mushrooms now”) in a restaurant.

The next time you create a checklist, take care to ensure it is precise, user friendly and includes only items of the highest importance

Checklists should be as short as possible, include all essential steps and leave no room for misunderstandings.

Today’s complex tasks can no longer be left to a lone hero’s expertise; we need teams.

We often hope for a hero to stride into a fearsome situation and, using a lifetime of skill and experience, solve all the problems in one fell swoop. The idea that one person’s expertise is enough to solve our problems is certainly alluring. But it is also inaccurate.

In complex and dangerous situations, it is the team that really counts.

There was a time in engineering when buildings were completed by master builders who oversaw the whole project. These days, however, the completion of a single construction project requires interaction between professionals who deal with everything from mechanics and masonry to waterproofing and rodent control.

Teams are especially essential when dealing with emergencies and critical situations. In 2009, after the Hudson River plane crash, the media eagerly saluted Chesley B. Sullenberger as “Captain America” – the hero of the miraculous crash-landing in which no one was killed. Yet Sullenberger insisted it was a team effort. As information on the accident came through, it became evident the plane would not have landed as safely as it did without the combined effort of Sullenberger, first officer Jeffrey Skiles and the rest of the crew.

In medicine, too, patients undergoing an operation require more than just a surgeon. Anaesthetists, nurses and surgeons must all work together and use their individual specialities as a team to successfully perform a procedure.

When we are faced with pressure or complexity, we must acknowledge that it is often the actions and skills of many, as opposed to those of one person, that make a complex procedure successful.

Today’s complex tasks can no longer be left to a lone hero’s expertise; we need teams.

Team communication is vital in complex situations and can be greatly enhanced by a checklist.

Imagine a flight crew landing a plane. Now think how disastrous it would be in this complicated, intense situation if they could not communicate with each other: the captain would not know if it was clear to land, the co-pilot would not know when or if they should take the controls, and flight attendants would have no clue when to conduct safety checks.

Teams working on complex tasks need seamless communication. In the above example, the flight crew could have a checklist to follow, but unless they communicate clearly, that checklist is useless.

Communication can be enhanced by including steps within a checklist that are aimed at improving the flow of information. For example, Joe Salvia, a structural engineer in Boston, uses “submittal” checklists outlining when teams involved in a construction should update, check on and collaborate with each other before advancing to the next stage.

Another checklist step that can improve communication is a team “huddle” – an opportunity at the start of a procedure for team members to introduce themselves and discuss any possible complications. Studies have shown that people who don’t know each other’s names do not work together as well as those who do. For this reason, a huddle was included as a mandatory step in the author’s Safe Surgery Saves Lives program checklist. This more communicative approach to teamwork correlated with a reduction in medical complications.

Communication within teams is vital under pressured circumstances. Teams are likely to be more successful at following procedure checklists when they have predefined opportunities to communicate.

Team communication is vital in complex situations and can be greatly enhanced by a checklist.

Medical checklists have already saved many lives.

It’s hard to imagine that a simple checklist could make a significant impact on the world. Yet medical programs studying the use of checklists have shown that they have prevented mistakes, saved money and – most importantly – saved lives.

One study carried out by critical care specialist Peter Pronovost, called the Keystone Initiative, aimed to reduce the number of infections from central line catheters inserted into the veins of intensive care patients. Central lines are easily and frequently infected (for example, by being touched with unsterilized hands), causing potentially lethal complications for patients. Pronovost employed a checklist to see if it would reduce infections. It was a success; the initiative ended up saving $175 million and 1,500 lives over 18 months.

Drawing inspiration from Pronovost and the fields of engineering and aviation, the author and the World Health Organization developed a checklist to be tested in eight hospitals around the world, in what was named the Safe Surgery Saves Lives program. The hospitals were asked to use this surgical checklist, which consisted of nineteen essential items ranging from discussing the patient’s expected blood loss to confirming that they actually had the correct patient. The results were astounding; deaths from surgeries across the eight hospitals were reduced by 47 percent.

The author also witnessed the power of the checklist first hand. While running through a surgical check regarding expected blood loss, it turned out that extra units of blood had not been set aside for the patient in case they were needed. Gawande didn’t expect the patient to need them but, keeping to the checklist, extra blood was organized. During the surgery, Gawande made an accidental tear causing cardiac arrest in the patient. The extra blood turned out to be vital and Gawande is sure that without the checklist he would have killed his patient.

Using a simple checklist is not only a powerful tool but may also mean the difference between life and death.

Medical checklists have already saved many lives.

Checklists can be effective in diverse settings.

Many of us work in complex or high-pressure environments that, like the field of medicine, demand care and precision, such as in finance or the restaurant industry. The good news is that, in such intense environments, checklists really make a difference in helping us work more effectively.

Take, for instance, chef Jody Adams at Rialto Restaurant in Boston. The checklists Jody uses are what most would call recipes. Yet recipes and checklists share the same function: they tell us what needs to be done and when. In addition to having her recipes on display at her kitchen workstations, the restaurant staff also make checklists to ensure the special requirements of individual customers are met. Once the dishes are ready to be served, they receive a final check by the sous chef or Jody herself to make sure they meet Jody’s standards. This checklist system enables Rialto to deliver consistently exquisite dishes to customers, and it is no surprise that Jody has won awards for her expertise or that the restaurant often makes “best-restaurant” lists.

Financiers, too, can use checklists to help them avoid unnecessary risk as a result of rash or uninformed decisions. “Cook,” an anonymous investor and director of a fund worth billions of dollars, uses a “Day Three Checklist,” which helps him and his team decide whether to invest in a company or not. The checklist offers Cook a huge advantage: efficiency. This careful and quick method for evaluating investments gives him an edge over other investors.

From ensuring high-quality dining experiences to helping rake in the big bucks, the unassuming checklist is a versatile tool that can yield impressive results and be applied to a variety of different situations.

Checklists can be effective in diverse settings.

Summary

“The Problem of Extreme Complexity”

Humans like to think of themselves as being in complete control of their world, but, more often than not, they must deal with failure. Such defeats stem, in part, from what philosophers Samuel Gorovitz and Alasdair MacIntyre call “necessary fallibility”; that is, despite scientific advances, some efforts people pursue are “simply beyond” human capacity. In areas of great achievement, such as erecting skyscrapers, predicting violent weather and performing lifesaving surgery, even experts must humbly concede the limitations of advanced training and years of experience.

“Much of the world and universe is – and will remain – outside our understanding and control.”

Error-based failure happens for two reasons: “ignorance and ineptitude.” Ignorance stems from the fact that people still have a lot to learn about the world and how it works. Ineptitude occurs when knowledge exists but people don’t apply it correctly. For example, in medicine, research has illuminated staggering amounts of knowledge about human health, so much so that ineptitude is now as great a problem as ignorance. Furthermore, sometimes the problem is “‘eptitude’ – making sure [to] apply the knowledge…consistently and correctly.”

“The volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely or reliably. Knowledge has both saved us and burdened us.”

Despite advances in technology, mistakes happen daily in every field that requires “mastery of complexity and of large amounts of knowledge.” Think of all the gaffes that make the news: medical blunders, bad software design, legal errors, troubled fiscal systems, botched handling of weather disasters, and more. “Failures of ignorance” are easier to forgive, but most people feel incensed when others don’t implement existing knowledge properly and thereby do harm. Trained, hardworking, dedicated professionals in all fields regularly and frequently make avoidable mistakes. The solution may seem “ridiculous in its simplicity”: Use a checklist.

The Checklist

A three-year-old girl fell into an icy pond near the Austrian Alps and was underwater for 30 minutes before her parents found her, pulled her ashore and began CPR. When rescuers arrived eight minutes later, her body temperature was 66°F (19°C), and she showed no signs of life. Nonetheless, medics airlifted her to the small local hospital where a surgical team cut into her chest, even though she had been lifeless for 90 minutes. Machines kept her blood flowing, and, when her body temperature rose to normal six hours later, doctors performed a cardiac bypass. Within two days, all organs except her brain returned to normal. She remained in a coma for more than a week. After extensive rehabilitation, she was totally back to normal by her fifth birthday. The lead cardiac surgeon attributed the team’s success to his earlier insistence on using a set of simple checklists to remind rescue squads and the hospital phone operator about the detailed steps to take to prepare the surgical team for a patient’s arrival.

“Checklists “provide a kind of cognitive net. They catch mental flaws inherent in all of us – flaws of memory and attention and thoroughness.”

In October 1935, the US Army Air Corps had aircraft manufacturers compete to build the “next-generation long-range bomber.” Boeing’s design had the lead; everyone thought the flight trials would be just a formality. But, minutes after its smooth takeoff, the giant four-engine Model 299 stalled and “crashed in a fiery explosion.” The veteran aviator who died in the crash had forgotten to release a lock. Rather than call for redesigning the plane or the training, some test pilots developed a checklist for flyers to review during takeoff. Just requiring them to use an index-card-sized checklist saved Boeing from bankruptcy and turned the Model 299 into the B-17 bombers that fought Nazi Germany. In 1.8 million flight miles, B-17s have never had an accident.

“Expertise is valuable but most certainly not sufficient.”

Many professionals, including medics, lawyers, architects, firefighters and police officers, face the same problem as the 1935 test pilots: Their jobs “have become too much airplane for one person to fly.” In a complex setting, professionals often face two key challenges: too much information to remember and too many distractions to attend to every detail. Whether building a skyscraper or buying recipe ingredients, if you “miss just one key thing, you might as well not have made the effort.” A checklist can make the difference.

“The End of the Master Builder”

From medieval times until the mid-20th century, “Master Builders” designed, engineered and erected great structures. These craftsmen ruled the entire building process from concept to completion. Today, however, advances in every aspect of construction “overwhelmed the abilities of any individual to master them.” The building profession split into architects, engineers and contractors, each of which has specialities and subspecialities. Knowing that they have “no margin for error” and that “failure is not an option,” these professionals developed a way to work together using a complex system of written checklists for each step of the construction process.

“You want people to make sure to get the stupid stuff right. Yet you also want to leave room for craft and judgment and the ability to respond to unexpected difficulties that arise along the way.”

No one authorizes or performs a task, no matter how small, without checking if preceding tasks are complete. Contractors use large wall-mounted paper charts to track each small step visually as it happens, and they use project-management software and communications systems. That is now the industry standard. A 2003 study cites an average of “just 20 serious [US] building failures per year…an annual avoidable failure rate of less than 0.00002%.” Checklists work.

The Idea

One “particularly tantalizing aspect” of construction is that builders push power out to on-the-ground practitioners to make decisions in the face of unanticipated events. Most central authorities, conversely, make checklists for their subordinates but hesitate to let those staffers make big decisions. Checklists work for organizing and overseeing routine tasks, but not for operating in crises, as Hurricane Katrina proved. Federal Emergency Management Agency officials refused to abandon command-and-control management despite worsening conditions; they should have pushed decision making “out of the center as far as possible.”

“The evidence of how slow we’ve been to adapt is the extraordinarily high rate at which care for patients is duplicated or flawed or completely uncoordinated.”

Retail giant Walmart got it right. Immediately after Katrina, the company gave its local store managers full permission to do whatever they could to help. Some gave away entire inventories to people needing emergency supplies. Some gave first responders food, tools and sleeping bags, using just a “crude paper-slip credit system” to keep track. Senior executives focused less on issuing orders and more on communication. The lesson is that complex, uncertain situations – when no one person or central agency can possibly know all that must be known – require a two-pronged mechanism to ensure that no one misses the “stupid but critical stuff” and that people keep talking to each other as they resolve the crisis.

“The First Try”

In 2006, after joining an international World Health Organization (WHO) group to tackle the growing dangers associated with surgeries, author Dr. Atul Gawande, a surgeon, and his research team found that, globally, surgical complications led to at least seven million deaths and one million disabilities each year. WHO wanted a “measurable, inexpensive and substantial reduction in overall complications from surgery.” The team rejected unfeasible remedies, but a study on the use of checklists to improve health persuaded them to take that path.

“A single type of error can affect thousands, but because it usually touches only one person at a time, we tend not to search as hard for explanations.”

In one case history, field workers distributed bars of antibacterial soap in poor neighborhoods in Karachi, Pakistan, teaching residents how to use the soap as part of a checklist of six daily routines for personal hygiene, food preparation and child care. During the one-year trial, bouts of diarrhea in children fell 52%, pneumonia fell 48% and the skin disease impetigo fell 35%. Interestingly, participants already used bar soap in their homes, but not correctly or often enough.

“Just ticking boxes [on a checklist] is not the ultimate goal. Embracing a culture of teamwork and discipline is.”

Another example that helped convince the WHO group was a short checklist used just before initial appendectomy incisions at Columbus Children’s Hospital where more than a third of patients “failed to get the right antibiotic at the right time.” Nurses routinely placed a small metal tent inscribed “Cleared for Takeoff” over the scalpel and were given new authority to stop the surgeon if even one step was omitted, effectively distributing the power. After three months, 89% of patients received the correct antibiotic in a timely way, and, after ten months, 100% did. Checklists also improved the operating-room working environment at the University of Toronto, Johns Hopkins and the California-based Kaiser health system hospitals. Checklists requiring the surgical team to introduce themselves to one another and to discuss and confirm all aspects of the procedure at hand directly led to enhanced levels of teamwork and surgical results.

“The Checklist Factory”

Veteran pilot Daniel Boorman, who spent 20 years creating checklists and flight deck controls for Boeing, warns against bad checklists that are “vague and imprecise, too long, hard to use, impractical, and made by desk jockeys with no awareness of the situations in which they are to be deployed.” Conversely, good checklists are “precise, efficient, to the point and easy to use in even the most difficult situations.” When compiling a checklist, don’t spell out every single step in bureaucratic detail; use simple words in the lingo of your field. Fit your list on one piece of paper and use both upper- and lowercase type (preferably sans serif). Test and refine your checklist in the real world.

“We are not built for discipline. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.”

Good checklists focus on the “killer items” – the ones that are “most dangerous to overlook” and that people are most likely to skip. Boeing uses two types of checklists: “DO-CONFIRM” to verify that pilots carry out critical actions and “READ-DO” for specifying the steps pilots take while doing a specific action. But even the best checklist cannot force anyone to use it. Aviators learn that their recollection and judgment are fallible. Good pilots – unlike many surgeons – understand and accept their limitations. When facing a calamity, pilots are “astonishingly willing” to use their checklists.

“The Test”

The WHO group met again in Geneva in spring 2007 to eliminate items that took extra time during the checklist procedure. Some of the proposed cuts might have made a life-or-death difference, depending on the country, the hospital or the surgery. The “final WHO safe surgery checklist” has 19 checks: seven before administering anesthesia, seven before incision, and five after the operation but still in the operating room. WHO gathered data on surgical complications and tested the checklist in eight hospitals worldwide, four in high-income countries – the US, Canada, England and New Zealand – and four in low- and middle-income nations – the Philippines, Jordan, India and Tanzania. In spring 2008, all eight hospitals educated their staff members and implemented the two-minute, 19-item checklist. “Pockets of resistance notwithstanding,” the checklist was in use in every study OR within a month of introduction.

“Checklists must not become ossified mandates that hinder rather than help. Even the simplest requires frequent revisitation and ongoing refinement.”

After just three months of using the checklists, major postsurgical complications dropped by 36%; deaths, by 47%; infections, by nearly 50%; and follow-up surgeries to correct problems, by 25%. Of 4,000 patients, only 277 developed serious complications, compared with 435 patients in prechecklist statistics. The WHO checklist “spared more than 150 people from harm – and 27 of them from death.” Follow-up surveys of more than 250 OR staffers revealed that 80% found the checklist easy to use and 78% saw it prevent a surgical mistake.

“The Age of Checklists”

By the end of 2009, more than 12 nations committed to using checklists in their hospitals; hospital associations in 20 US states pledged to track the results of checklist usage; 10% of US hospitals either adopted or planned to adopt checklists; and globally, more than 2,000 hospitals were using them. Checklists offer opportunities “not just in medicine but in virtually any endeavor.” For example, interviews with three successful investors reveal that each one attributes his success to using checklists based on his experience and that of respected peers; Warren Buffett also uses a “mental checklist process.”

“In the end, a checklist is only an aid. If it doesn’t aid, it’s not right. But if it does, we must be ready to embrace the possibility.”

Yet people aren’t very disciplined, so efforts to introduce the discipline of checklists in other fields have been an uphill battle. Little research goes into examining failures “in teaching, in law, in government programs, in the financial industry or elsewhere.” When the same mistakes keep happening, it’s time to take a different tack: Try a checklist.

Conclusion

The main message in this book:

Much more than a to-do list for the inept, a checklist can be an incredibly effective tool for professionals and experts. Using a well-crafted checklist in complex situations ensures we catch potentially fatal errors and dangerous oversights.

Actionable ideas from this book in book summary:

Still experiencing errors in your tasks, despite your experience and expertise? Use a checklist!

We can be stubborn when it comes to making checklists for ourselves, especially when we know exactly what we are doing. However, it is often the skilled professions that benefit the most from making a checklist. One of the reasons for this is that we often skip over or forget the obvious “dumb stuff,” falsely assuming that focusing on more complex things is far more important. The dumb stuff, however, is often essential to the procedure at hand. Using a checklist helps you avoid letting the necessary stuff slip through the cracks, and you just might find you make far fewer errors because of it.

About the author

Atul Gawande is a MacArthur Fellow, a surgeon at Brigham and Women’s Hospital in Boston, and an associate professor at Harvard Medical School.

Table of Contents

Introduction 1
1 The Problem of Extreme Complexity 15
2 The Checklist 32
3 The End of the Master Builder 48
4 The Idea 72
5 The First Try 86
6 The Checklist Factory 114
7 The Test 136
8 The Hero in the Age of Checklists 158
9 The Save 187
Appendix: Example Checklists 195
Notes on Sources 201
Acknowledgments 211