“(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.
Atul Gawande is a general surgeon at Brigham and Women’s Hospital in Boston, Massachusetts, and a professor of surgery at Harvard Medical School. As well as writing for the New York Times, he is also author of Better and Complications, the latter of which was a National Book Award finalist. In 2010, Gawande was named one of the world’s 100 most influential thinkers by TIME magazine.
Atul Gawande is the author of several bestselling books: Complications, a finalist for the National Book Award; Better; The Checklist Manifesto, and Being Mortal. He is also a surgeon at Brigham and Women’s Hospital in Boston, a staff writer for The New Yorker, and a professor at Harvard Medical School and the Harvard School of Public Health. He has won the Lewis Thomas Prize for Writing about Science, a MacArthur Fellowship, and two National Magazine Awards. In his work in public health, he is Founder and Chair of Ariadne Labs, a joint center for health systems innovation, and Lifebox, a nonprofit organization making surgery safer globally. He is also chair of Haven, where he was CEO from 2018-2020. He and his wife have three children and live in Newton, Massachusetts.
Genres
Productivity, Career Success, Business Self Help, Medicine, Medical, Science, Psychology, Personal Development, Management, Family Practice Medicine, Hospital Administration, Time Management
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
Overview
The New York Times bestselling author of Being Mortal and Complications reveals the surprising power of the ordinary checklist.
We live in a world of great and increasing complexity, where even the most expert professionals struggle to master the tasks they face. Longer training, ever more advanced technologies—neither seems to prevent grievous errors. But in a hopeful turn, acclaimed surgeon and writer Atul Gawande finds a remedy in the humblest and simplest of techniques: the checklist. First introduced decades ago by the U.S. Air Force, checklists have enabled pilots to fly aircraft of mind-boggling sophistication. Now innovative checklists are being adopted in hospitals around the world, helping doctors and nurses respond to everything from flu epidemics to avalanches. Even in the immensely complex world of surgery, a simple ninety-second variant has cut the rate of fatalities by more than a third.
In riveting stories, Gawande takes us from Austria, where an emergency checklist saved a drowning victim who had spent half an hour underwater, to Michigan, where a cleanliness checklist in intensive care units virtually eliminated a type of deadly hospital infection. He explains how checklists actually work to prompt striking and immediate improvements. And he follows the checklist revolution into fields well beyond medicine, from disaster response to investment banking, skyscraper construction, and businesses of all kinds.
An intellectual adventure in which lives are lost and saved and one simple idea makes a tremendous difference, The Checklist Manifesto is essential reading for anyone working to get things right.
In his latest bestseller, Atul Gawande shows what the simple idea of the checklist reveals about the complexity of our lives and how we can deal with it.
The modern world has given us stupendous know-how. Yet avoidable failures continue to plague us in health care, government, the law, the financial industry—in almost every realm of organized activity. And the reason is simple: the volume and complexity of knowledge today has exceeded our ability as individuals to properly deliver it to people—consistently, correctly, safely. We train longer, specialize more, use ever-advancing technologies, and still we fail. Atul Gawande makes a compelling argument that we can do better, using the simplest of methods: the checklist. In riveting stories, he reveals what checklists can do, what they can’t, and how they could bring about striking improvements in a variety of fields, from medicine and disaster recovery to professions and businesses of all kinds. And the insights are making a difference. Already, a simple surgical checklist from the World Health Organization designed by following the ideas described here has been adopted in more than twenty countries as a standard for care and has been heralded as “the biggest clinical invention in thirty years” (The Independent).
Review/Endorsements/Praise/Award
“I read The Checklist Manifesto in one sitting yesterday, which is an amazing tribute to the book that Gawande has crafted. Not only is the book loaded with fascinating stories, but it honestly changed the way I think about the world. It is the best book I’ve read in ages.” ―Steven Levitt, author of Freakonomics
“Few medical writers working today can transmit the gore-drenched terror of an operation that suddenly goes wrong―a terror that has a special resonance when it is Dr. Gawande himself who makes the initial horrifying mistake. And few can make it as clear as he can what exactly is at stake in the effort to minimize calamities.” ―The New York Times
“Even skeptical readers will find the evidence staggering. . . . Thoughtfully written and soundly defended, this book calls for medical professionals to improve patient care by adopting a basic, common-sense approach.” ―The Washington Post
“A persuasive champion of his cause.” ―The Economist
“The Checklist Manifesto is beautifully written, engaging, and convincingly makes the case for adopting checklists in medicine, a project to which Gawande has devoted significant time over the last several years. . . . It is in many ways the most personal of his books, a direct call to action to change the way health care is delivered through straightforward and simple, yet proven, means. It is a call that deserves to be heard and heeded.” ―Journal of the American Medical Association
“Gawande deftly weaves in examples of checklist successes in diverse fields like aviation and skyscraper construction. . . . Fascinating reading.” ―New York Times Book Review
“This is a brilliant book about an idea so simple it sounds dumb until you hear the case for it. Atul Gawande presents an argument so strong that I challenge anyone to go away from this book unconvinced.” ―The Seattle Times
“Fascinating . . . presents a convincing case that adopting more checklists will surely help.” ―Bloomberg News
“Gawande argues convincingly and eloquently.” ―San Francisco Chronicle
“The scope goes well beyond medicine. . . Read this book and you might find yourself making checklists for the most mundane tasks–and be better off for it.” ―BusinessWeek
“A vivid, punchy exposition of an intriguing idea: that by-the-book routine trumps individual prowess.” ―Publishers Weekly
“Maintains the balance between accessibility and precision. He manages to be vivid without being gruesome. . . .” ―The Guardian (UK)
“Riveting and thought-provoking.” ―The Times (UK)
“Eye-popping. . . Gawande writes with vigor and clarity.” ―New Haven Advocate
“Gawande manages to capture medicine in all of its complex and chaotic glory, and to put it, still squirming with life, down on the page. With this book, Gawande inspires all of us, doctor or not, to be better.” ―The New York Times Book Review on Better
“Gawande is unassuming in every way, and yet his prose is infused with steadfast determination and hope. If society is the patient here, I can’t think of a better guy to have our back.” ―The Boston Globe on Better
“Remarkable . . . Brings to modern high-tech medicine the same clinical watchfulness that writers such as Williams and Sacks have brought to bear on the lives and emotions of often fragile patients.” ―Sherwin B. Nuland, The New York Review of Books, on Better
“Gawande is a writer with a scalpel pen and an X-ray eye. Diagnosis: riveting.” ―TIME, on Better
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1. THE PROBLEM OF EXTREME COMPLEXITY
Some time ago I read a case report in the Annals of Thoracic Surgery. It was, in the dry prose of a medical journal article, the story of a nightmare. In a small Austrian town in the Alps, a mother and father had been out on a walk in the woods with their three- year-old daughter. The parents lost sight of the girl for a moment and that was all it took. She fell into an icy fishpond. The parents frantically jumped in after her. But she was lost beneath the surface for thirty minutes before they finally found her on the pond bottom. They pulled her to the surface and got her to the shore. Following instructions from an emergency response team reached on their cell phone, they began cardiopulmonary resuscitation.
Rescue personnel arrived eight minutes later and took the first recordings of the girl’s condition. She was unresponsive. She had no blood pressure or pulse or sign of breathing. Her body temperature was just 66 degrees. Her pupils were dilated and unreactive to light, indicating cessation of brain function. She was gone.
But the emergency technicians continued CPR anyway. A helicopter took her to the nearest hospital, where she was wheeled directly into an operating room, a member of the emergency crew straddling her on the gurney, pumping her chest. A surgical team got her onto a heart- lung bypass machine as rapidly as it could. The surgeon had to cut down through the skin of the child’s right groin and sew one of the desk- size machine’s silicone rubber tubes into her femoral artery to take the blood out of her, then another into her femoral vein to send the blood back. A perfusionist turned the pump on, and as he adjusted the oxygen and temperature and flow through the system, the clear tubing turned maroon with her blood. Only then did they stop the girl’s chest compressions.
Between the transport time and the time it took to plug the machine into her, she had been lifeless for an hour and a half. By the two- hour mark, however, her body temperature had risen almost ten degrees, and her heart began to beat. It was her first organ to come back.
After six hours, the girl’s core reached 98.6 degrees, normal body temperature. The team tried to shift her from the bypass machine to a mechanical ventilator, but the pond water and debris had damaged her lungs too severely for the oxygen pumped in through the breathing tube to reach her blood. So they switched her instead to an artificial- lung system known as ECMO— extracorporeal membrane oxygenation. To do this, the surgeons had to open her chest down the middle with a power saw and sew the lines to and from the portable ECMO unit directly into her aorta and her beating heart.
The ECMO machine now took over. The surgeons removed the heart- lung bypass machine tubing. They repaired the vessels and closed her groin incision. The surgical team moved the girl into intensive care, with her chest still open and covered with sterile plastic foil. Through the day and night, the intensive care unit team worked on suctioning the water and debris from her lungs with a fiberoptic bronchoscope. By the next day, her lungs had recovered sufficiently for the team to switch her from ECMO to a mechanical ventilator, which required taking her back to the operating room to unplug the tubing, repair the holes, and close her chest.
Over the next two days, all the girl’s organs recovered— her liver, her kidneys, her intestines, everything except her brain. A CT scan showed global brain swelling, which is a sign of diffuse damage, but no actual dead zones. So the team escalated the care one step further. It drilled a hole into the girl’s skull, threaded a probe into the brain to monitor the pressure, and kept that pressure tightly controlled through constant adjustments in her fluids and medications. For more than a week, she lay comatose. Then, slowly, she came back to life.
First, her pupils started to react to light. Next, she began to breathe on her own. And, one day, she simply awoke. Two weeks after her accident, she went home. Her right leg and left arm were partially paralyzed. Her speech was thick and slurry. But she underwent extensive outpatient therapy. By age five, she had recovered her faculties completely. Physical and neurological examinations were normal. She was like any little girl again.
What makes this recovery astounding isn’t just the idea that someone could be brought back after two hours in a state that would once have been considered death. It’s also the idea that a group of people in a random hospital could manage to pull off something so enormously complicated. Rescuing a drowning victim is nothing like it looks on television shows, where a few chest compressions and some mouth- to- mouth resuscitation always seem to bring someone with waterlogged lungs and a stilled heart coughing and sputtering back to life. To save this one child, scores of people had to carry out thousands of steps correctly: placing the heart- pump tubing into her without letting in air bubbles; maintaining the sterility of her lines, her open chest, the exposed fluid in her brain; keeping a temperamental battery of machines up and running. The degree of difficulty in any one of these steps is substantial. Then you must add the difficulties of orchestrating them in the right sequence, with nothing dropped, leaving some room for improvisation, but not too much.
For every drowned and pulseless child rescued, there are scores more who don’t make it— and not just because their bodies are too far gone. Machines break down; a team can’t get moving fast enough; someone fails to wash his hands and an infection takes hold. Such cases don’t get written up in the Annals of Thoracic Surgery, but they are the norm, though people may not realize it.
I think we have been fooled about what we can expect from medicine—fooled, one could say, by penicillin. Alexander Fleming’s 1928 discovery held out a beguiling vision of health care and how it would treat illness or injury in the future: a simple pill or injection would be capable of curing not just one condition but perhaps many. Penicillin, after all, seemed to be effective against an astonishing variety of previously untreatable infectious diseases. So why not a similar cure- all for the different kinds of cancer? And why not something equally simple to melt away skin burns or to reverse cardiovascular disease and strokes?
Medicine didn’t turn out this way, though. After a century of incredible discovery, most diseases have proved to be far more particular and difficult to treat. This is true even for the infections doctors once treated with penicillin: not all bacterial strains were susceptible and those that were soon developed resistance. Infections today require highly individualized treatment, sometimes with multiple therapies, based on a given strain’s pattern of anti biotic susceptibility, the condition of the patient, and which organ systems are affected. The model of medicine in the modern age seems less and less like penicillin and more and more like what was required for the girl who nearly drowned. Medicine has become the art of managing extreme complexity— and a test of whether such complexity can, in fact, be humanly mastered.
The ninth edition of the World Health Organization’s international classification of diseases has grown to distinguish more than thirteen thousand different diseases, syndromes, and types of injury— more than thirteen thousand different ways, in other words, that the body can fail. And, for nearly all of them, science has given us things we can do to help. If we cannot cure the disease, then we can usually reduce the harm and misery it causes. But for each condition the steps are different and they are almost never simple. Clinicians now have at their disposal some six thousand drugs and four thousand medical and surgical procedures, each with different requirements, risks, and considerations. It is a lot to get right.
There is a community clinic in Boston’s Kenmore Square affiliated with my hospital. The word clinic makes the place sound tiny, but it’s nothing of the sort. Founded in 1969, and now called Harvard Vanguard, it aimed to provide people with the full range of outpatient medical services they might need over the course of their lives. It has since tried to stick with that plan, but doing so hasn’t been easy. To keep up with the explosive growth in medical capabilities, the clinic has had to build more than twenty facilities and employ some six hundred doctors and a thousand other health professionals covering fifty- nine specialties, many of which did not exist when the clinic first opened. Walking the fifty steps from the fifth- floor elevator to the general surgery department, I pass offices for general internal medicine, endocrinology, genetics, hand surgery, laboratory testing, nephrology, ophthalmology, orthopedics, radiology scheduling, and urology— and that’s just one hallway.
To handle the complexity, we’ve split up the tasks among various specialties. But even divvied up, the work can become overwhelming. In the course of one day on general surgery call at the hospital, for instance, the labor floor asked me to see a twenty-five- year- old woman with mounting right lower abdominal pain, fever, and nausea, which raised concern about appendicitis, but she was pregnant, so getting a CT scan to rule out the possibility posed a risk to the fetus. A gynecological oncologist paged me to the operating room about a woman with an ovarian mass that upon removal appeared to be a metastasis from pancreatic cancer; my colleague wanted me to examine her pancreas and decide whether to biopsy it. A physician at a nearby hospital phoned me to transfer a patient in intensive care with a large cancer that had grown to obstruct her kidneys and bowel and produce bleeding that they were having trouble controlling. Our internal medicine service called me to see a sixty- one- year- old man with emphysema so severe he had been refused hip surgery because of insufficient lung reserves; now he had a severe colon infection— an acute diverticulitis— that had worsened despite three days of antibiotics, and surgery seemed his only option. Another service asked for help with a fifty- two- year- old man with diabetes, coronary artery disease, high blood pressure, chronic kidney failure, severe obesity, a stroke, and now a strangulating groin hernia. And an internist called about a young, otherwise healthy woman with a possible rectal abscess to be lanced.
Confronted with cases of such variety and intricacy— in one day, I’d had six patients with six completely different primary medical problems and a total of twenty- six different additional diagnoses— it’s tempting to believe that no one else’s job could be as complex as mine. But extreme complexity is the rule for almost everyone. I asked the people in Harvard Vanguard’s medical records department if they would query the electronic system for how many different kinds of patient problems the average doctor there sees annually. The answer that came back flabbergasted me. Over the course of a year of office practice— which, by definition, excludes the patients seen in the hospital— physicians each evaluated an average of 250 different primary diseases and conditions. Their patients had more than nine hundred other active medical problems that had to be taken into account. The doctors each prescribed some three hundred medications, ordered more than a hundred different types of laboratory tests, and performed an average of forty different kinds of office procedures— from vaccinations to setting fractures.
Even considering just the office work, the statistics still didn’t catch all the diseases and conditions. One of the most common diagnoses, it turned out, was “Other.” On a hectic day, when you’re running two hours behind and the people in the waiting room are getting irate, you may not take the time to record the precise diagnostic codes in the database. But, even when you do have the time, you commonly find that the particular diseases your patients have do not actually exist in the computer system.
The software used in most American electronic records has not managed to include all the diseases that have been discovered and distinguished from one another in recent years. I once saw a patient with a ganglioneuroblastoma (a rare type of tumor of the adrenal gland) and another with a nightmarish genetic condition called Li- Fraumeni syndrome, which causes inheritors to develop cancers in organs all over their bodies. Neither disease had yet made it into the pull- down menus. All I could record was, in so many words, “Other.” Scientists continue to report important new genetic findings, subtypes of cancer, and other diagnoses— not to mention treatments— almost weekly. The complexity is increasing so fast that even the computers cannot keep up.
But it’s not only the breadth and quantity of knowledge that has made medicine complicated. It is also the execution— the practical matter of what knowledge requires clinicians to do. The hospital is where you see just how formidable the task can be. A prime example is the place the girl who nearly drowned spent most of her recovery— the intensive care unit.
It’s an opaque term, intensive care. Specialists in the field prefer to call what they do critical care, but that still doesn’t exactly clarify matters. The nonmedical term life support gets us closer. The damage that the human body can survive these days is as awesome as it is horrible: crushing, burning, bombing, a burst aorta, a ruptured colon, a massive heart attack, rampaging infection. These maladies were once uniformly fatal. Now survival is commonplace, and a substantial part of the credit goes to the abilities intensive care units have developed to take artificial control of failing bodies. Typically, this requires a panoply of technology— a mechanical ventilator and perhaps a tracheostomy tube if the lungs have failed, an aortic balloon pump if the heart has given out, a dialysis machine if the kidneys don’t work. If you are unconscious and can’t eat, silicone tubing can be surgically inserted into your stomach or intestines for formula feeding. If your intestines are too damaged, solutions of amino acids, fatty acids, and glucose can be infused directly into your bloodstream.
On any given day in the United States alone, some ninety thousand people are admitted to intensive care. Over a year, an estimated five million Americans will be, and over a normal lifetime nearly all of us will come to know the glassed bay of an ICU from the inside. Wide swaths of medicine now depend on the life support systems that ICUs provide: care for premature infants; for victims of trauma, strokes, and heart attacks; for patients who have had surgery on their brains, hearts, lungs, or major blood vessels. Critical care has become an increasingly large portion of what hospitals do. Fifty years ago, ICUs barely existed. Now, to take a recent random day in my hospital, 155 of our almost 700 patients are in intensive care. The average stay of an ICU patient is four days, and the survival rate is 86 percent. Going into an ICU, being put on a mechanical ventilator, having tubes and wires run into and out of you, is not a sentence of death. But the days will be the most precarious of your life.
Fifteen years ago, Israeli scientists published a study in which engineers observed patient care in ICUs for twenty- four- hour stretches. They found that the average patient required 178 individual actions per day, ranging from administering a drug to suctioning the lungs, and every one of them posed risks. Remarkably, the nurses and doctors were observed to make an error in just 1 percent of these actions— but that still amounted to an average of two errors a day with every patient. Intensive care succeeds only when we hold the odds of doing harm low enough for the odds of doing good to prevail. This is hard. There are dangers simply in lying unconscious in bed for a few days. Muscles atrophy. Bones lose mass. Pressure ulcers form. Veins begin to clot. You have to stretch and exercise patients’ flaccid limbs daily to avoid contractures; you have to give subcutaneous injections of blood thinners at least twice a day, turn patients in bed every few hours, bathe them and change their sheets without knocking out a tube or a line, brush their teeth twice a day to avoid pneumonia from bacterial buildup in their mouths. Add a ventilator, dialysis, and the care of open wounds, and the difficulties only accumulate.
The story of one of my patients makes the point. Anthony DeFilippo was a forty- eight- year- old limousine driver from Everett, Massachusetts, who started to hemorrhage at a community hospital during surgery for a hernia and gallstones. The surgeon was finally able to stop the bleeding but DeFilippo’s liver was severely damaged, and over the next few days he became too sick for the hospital’s facilities. I accepted him for transfer in order to stabilize him and figure out what to do. When he arrived in our ICU, at 1:30 a.m. on a Sunday, his ragged black hair was plastered to his sweaty forehead, his body was shaking, and his heart was racing at 114 beats a minute. He was delirious from fever, shock, and low oxygen levels.
“I need to get out!” he cried. “I need to get out!” He clawed at his gown, his oxygen mask, the dressings covering his abdominal wound.
“Tony, it’s all right,” a nurse said to him. “We’re going to help you. You’re in a hospital.”
He shoved her out of the way— he was a big man— and tried to swing his legs out of the bed. We turned up his oxygen flow, put his wrists in cloth restraints, and tried to reason with him. He eventually tired out and let us draw blood and give him antibiotics.
The laboratory results came back showing liver failure and a steeply elevated white blood cell count, indicating infection. It soon became evident from his empty urine bag that his kidneys had failed, too. In the next few hours, his blood pressure fell, his breathing worsened, and he drifted from agitation to near unconsciousness. Each of his organ systems, including his brain, was shutting down.
I called his sister, his next of kin, and told her the situation. “Do everything you can,” she said.
So we did. We gave him a syringeful of anesthetic, and a resident slid a breathing tube into his throat. Another resident “lined him up.” She inserted a thin two- inch- long needle and catheter through his upturned right wrist and into his radial artery, then sewed the line to his skin with a silk suture. Next, she put in a central line— a twelve- inch catheter pushed into the jugular vein in his left neck. After she sewed that in place, and an X-ray showed its tip floating just where it was supposed to— inside his vena cava at the entrance to his heart— she put a third, slightly thicker line, for dialysis, through his right upper chest and into the subclavian vein, deep under the collarbone.
We hooked a breathing tube up to a hose from a ventilator and set it to give him fourteen forced breaths of 100 percent oxygen every minute. We dialed the ventilator pressures and gas flow up and down, like engineers at a control panel, until we got the blood levels of oxygen and carbon dioxide where we wanted them. The arterial line gave us continuous arterial blood pressure measurements, and we tweaked his medications to get the pressures we liked. We regulated his intravenous fluids according to venous pressure measurements from his jugular line. We plugged his subclavian line into tubing from a dialysis machine, and every few minutes his entire blood volume washed through this artificial kidney and back into his body; a little adjustment here and there, and we could alter the levels of potassium and bicarbonate and salt, as well. He was, we liked to imagine, a simple machine in our hands.
But he wasn’t, of course. It was as if we had gained a steering wheel and a few gauges and controls, but on a runaway 18wheeler hurtling down a mountain. Keeping that patient’s blood pressure normal required gallons of intravenous fluid and a pharmacy shelf of drugs. He was on near- maximal ventilator support. His temperature climbed to 104 degrees. Less than 5 percent of patients with DeFilippo’s degree of organ failure make it home. A single misstep could easily erase those slender chances.
For ten days, though, we made progress. DeFilippo’s chief problem had been liver damage from his prior operation: the main duct from his liver was severed and was leaking bile, which is caustic— it digests the fat in one’s diet and was essentially eating him alive from the inside. He had become too sick to survive an operation to repair the leak. So once we had stabilized him, we tried a temporary solution— we had radiologists place a plastic drain, using CT guidance, through his abdominal wall and into the severed duct in order to draw out the leaking bile. They found so much that they had to place three drains— one inside the duct and two around it. But, as the bile drained out, his fevers subsided. His need for oxygen and fluids diminished, and his blood pressure returned to normal. He was beginning to mend. Then, on the eleventh day, just as we were getting ready to take him off the ventilator, he again developed high, spiking fevers, his blood pressure sank, and his blood- oxygen levels plummeted again. His skin became clammy. He got shaking chills.
We couldn’t understand what had happened. He seemed to have developed an infection, but our X-rays and CT scans failed to turn up a source. Even after we put him on four antibiotics, he continued to spike fevers. During one fever, his heart went into fibrillation. A Code Blue was called. A dozen nurses and doctors raced to his bedside, slapped electric paddles onto his chest, and shocked him. His heart responded and went back into rhythm. It took two more days for us to figure out what had gone wrong. We considered the possibility that one of his lines had become infected, so we put in new lines and sent the old ones to the lab for culturing. Forty- eight hours later, the results returned. All the lines were infected. The infection had probably started in one line, which perhaps was contaminated during insertion, and spread through DeFilippo’s bloodstream to the others. Then they all began spilling bacteria into him, producing the fevers and steep decline.
This is the reality of intensive care: at any point, we are as apt to harm as we are to heal. Line infections are so common that they are considered a routine complication. ICUs put five million lines into patients each year, and national statistics show that after ten days 4 percent of those lines become infected. Line infections occur in eighty thousand people a year in the United States and are fatal between 5 and 28 percent of the time, depending on how sick one is at the start. Those who survive line infections spend on average a week longer in intensive care. And this is just one of many risks. After ten days with a urinary catheter, 4 percent of American ICU patients develop a bladder infection. After ten days on a ventilator, 6 percent develop bacterial pneumonia, resulting in death 40 to 45 percent of the time. All in all, about half of ICU patients end up experiencing a serious complication, and once that occurs the chances of survival drop sharply.
It was another week before DeFilippo recovered sufficiently from his infections to come off the ventilator and two months before he left the hospital. Weak and debilitated, he lost his limousine business and his home, and he had to move in with his sister. The tube draining bile still dangled from his abdomen; when he was stronger, I was going to have to do surgery to reconstruct the main bile duct from his liver. But he survived. Most people in his situation do not.
Here, then, is the fundamental puzzle of modern medical care: you have a desperately sick patient and in order to have a chance of saving him you have to get the knowledge right and then you have to make sure that the 178 daily tasks that follow are done correctly— despite some monitor’s alarm going off for God knows what reason, despite the patient in the next bed crashing, despite a nurse poking his head around the curtain to ask whether someone could help “get this lady’s chest open.” There is complexity upon complexity. And even specialization has begun to seem inadequate. So what do you do?
The medical profession’s answer has been to go from specialization to superspecialization. I told DeFilippo’s ICU story, for instance, as if I were the one tending to him hour by hour. That, however, was actually an intensivist (as intensive care specialists like to be called). As a general surgeon, I like to think I can handle most clinical situations. But, as the intricacies involved in intensive care have grown, responsibility has increasingly shifted to super-specialists. In the past decade, training programs focusing on critical care have opened in most major American and Eu ro pe an cities, and half of American ICUs now rely on superspecialists.
Expertise is the mantra of modern medicine. In the early twentieth century, you needed only a high school diploma and a one- year medical degree to practice medicine. By the century’s end, all doctors had to have a college degree, a four- year medical degree, and an additional three to seven years of residency training in an individual field of practice— pediatrics, surgery, neurology, or the like. In recent years, though, even this level of preparation has not been enough for the new complexity of medicine. After their residencies, most young doctors today are going on to do fellowships, adding one to three further years of training in, say, laparoscopic surgery, or pediatric metabolic disorders, or breast radiology, or critical care. A young doctor is not so young nowadays; you typically don’t start in in de pen dent practice until your midthirties.
We live in the era of the superspecialist— of clinicians who have taken the time to practice, practice, practice at one narrow thing until they can do it better than anyone else. They have two advantages over ordinary specialists: greater knowledge of the details that matter and a learned ability to handle the complexities of the particular job. There are degrees of complexity, though, and medicine and other fields like it have grown so far beyond the usual kind that avoiding daily mistakes is proving impossible even for our most superspecialized.
There is perhaps no field that has taken specialization further than surgery. Think of the operating room as a particularly aggressive intensive care unit. We have anesthesiologists just to handle pain control and patient stability, and even they have divided into subcategories. There are pediatric anesthesiologists, cardiac anesthesiologists, obstetric anesthesiologists, neurosurgical anesthesiologists, and many others. Likewise, we no longer have just “operating room nurses.” They too are often subspecialized for specific kinds of cases.
Then of course there are the surgeons. Surgeons are so absurdly ultraspecialized that when we joke about right ear surgeons and left ear surgeons, we have to check to be sure they don’t exist. I am trained as a general surgeon but, except in the most rural places, there is no such thing. You really can’t do everything anymore. I decided to center my practice on surgical oncology— cancer surgery— but even this proved too broad. So, although I have done all I can to hang on to a broad span of general surgical skills, especially for emergencies, I’ve developed a particular expertise in removing cancers of endocrine glands.
The result of the recent de cades of ever- refined specialization has been a spectacular improvement in surgical capability and success. Where deaths were once a double- digit risk of even small operations, and prolonged recovery and disability was the norm, day surgery has become commonplace.
Yet given how much surgery is now done— Americans today undergo an average of seven operations in their lifetime, with surgeons performing more than fifty million operations annually— the amount of harm remains substantial. We continue to have upwards of 150,000 deaths following surgery every year— more than three times the number of road traffic fatalities. Moreover, research has consistently showed that at least half our deaths and major complications are avoidable. The knowledge exists. But however supremely specialized and trained we may have become, steps are still missed. Mistakes are still made.
Medicine, with its dazzling successes but also frequent failures, therefore poses a significant challenge: What do you do when expertise is not enough? What do you do when even the super-specialists fail? We’ve begun to see an answer, but it has come from an unexpected source— one that has nothing to do with medicine at all.
Excerpted from The Checklist Manifesto by Atul Gawande.
