The Checklist Manifesto

 How to Get Things Right


Atul Gawande

Metropolitan Books, 2009, 209 pp.   ISBN 978-0-8050-9174-8



Gawande is a general and endocrine surgeon in Boston, a staff writer for The New Yorker, and an associate professor at Harvard Medical School.  In today’s world we have stupendous know-how, but avoidable failures plague us because the volume and complexity of knowledge exceeds our individual ability to consistently, correctly, and safely use it.  Drawing examples from the worlds of surgery, air flight, and construction, Gawande shows how simple checklists can make a world of difference.  I was amazed at the numbers of preventable, serious errors that occur in the world’s most advanced hospitals.


We may fail because of ignorance or ineptitude.  The balance has shifted and it is most clear in medicine.  In the 1950s we didn’t know what caused heart attacks or how to prevent or treat them.  Today we have several ways to reduce the likelihood of a heart attack and a whole panel of effective therapies if you have one.  But there are abundant complexities and pitfalls.  At least 30% of stroke patients, 45% of asthma patients, and 60% of pneumonia patients receive incomplete or inappropriate care from their doctors!  (10)  Complexity is the issue.  Mistakes are frequent in almost any endeavor requiring mastery of complexity and large amounts of knowledge.  There is too much to manage and get right.  (11-12)  The volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably.”  The answer:  a checklist. (13)


The author tells a long involved story of a girl rescued after 30 minutes under water in the Alps.  The hospital was able to save her by a multitude of heroic measures.  The marvel is that everyone got it right.  Clinicians now have some six thousand drugs and 4000 medical and surgical procedures.  It’s a lot to get right.     


“Americans today undergo an average of seven operations in their lifetime, with surgeons performing more than fifty million operations annually…” (31) There are more than 150,000 deaths following surgery every year, 3 times the number of road traffic fatalities.  At least half are avoidable. 


When the B-17 was being flown in a flight competition in 1935, the air corps’ chief of flight testing crashed the plane and died.  He forgot one switch.  The plane was too complicated to be left to the memory of one person to fly it.  But after checklists were developed and used, the B-17 flew 1.8 million miles with an accident.  (34) 


In one hospital, researchers found that out of 5 simple steps to avoid infection, doctors skipped at least one step in a third of the patients. (38) They also “found that simply having the doctors and nurses in the ICU create their own checklists for what they thought should be done each day improved the consistency of care to the point that the average length of patient stay in intensive care dropped by half.” (39)  


The question when to follow one’s judgment and when to follow protocol is central to doing the job well.  You want to leave room for craft and judgment and the ability to respond to unexpected difficulties.  Checklists are clearly of help for simple problems.


So how do they get it all right when they build huge buildings with the sixteen different trades and all the sequential steps and all the machinery?  No longer does one master builder oversee everything.  On the walls are butcher-block-size printouts of check lists with line-by-line, day-by-day listings of every building task.  On another wall are similar lists of difficult and unexpected problems that must be addressed by the appropriate people.  Failure of communication is the biggest source of serious errors.  The U.S. has only about 20 serious ‘building failures’ per year, or less than 0.00002 percent.  (71)


Katrina revealed huge blockages in government aid getting to the right places.  “The trouble wasn’t a lack of sympathy among top officials.  It was a lack of understanding that, in the face of an extraordinarily complex problem, power needed to be pushed out of the center as far as possible.  Everyone was waiting for the cavalry, but a centrally run, government-controlled solution was not going to be possible.” (75) 


Oddly enough Wal-Mart did the best relief job.  The CEO issued a simple edict. “This company will respond to the level of this disaster.  A lot of you are going to have to make decisions above your level.  Make the best decision that you can with the information that’s available to you at the time, and above all, do the right thing.”  Wal-Mart got half of their stores reopened within 48 hours and then shifted to helping the people, distributing diapers, water, baby formula, ice, etc. and developing all kinds of creative make-shift methods including crude paper-slip credit systems for first responders. 


The lesson is that under deep complexity, efforts to dictate from the center will fail.  People need room to act and adapt.  They need a contradictory mix of freedom and expectation to coordinate and measure progress toward common goals.  Checklists can help achieve that balance, one set for the stupid but critical steps, the other to ensure people talk about, coordinate, and accept responsibility while being given the power to manage the unpredictables. 


Bad checklists are vague and imprecise, too long, hard to use, impractical.  Good checklists are precise, efficient, to the point, easy to use.  They do not try to spell out everything, only the most critical and important steps, the ones even highly skilled professionals might miss.  (120)  5 to 9 items in large print on one page is about right.  It has to be tested in the real world.  Very short checklists are employed at particular pause points. 


In 2004, surgeons throughout the world were performing some 230 million major operations annually, with estimates of complication rates for hospital surgery from 3 to 17 percent.  (87)  The author worked with a team from WHO to develop checklists for hospitals.  One of the items is for the team to talk to one another, to get acquainted.  Simply introducing themselves and mentioning possible concerns at the beginning of a case seems to help teamwork.  The final WHO safe surgery checklist spelled out 19 checks in all, 7 before anesthesia, 7 more after anesthesia but before incision, and 5 final checks before wheeling out the patient. 


As an example, here are the first 7:

  1. Confirm the patient identity
  2. Check that the surgical site is marked
  3. See that the pulse oximeter (monitors oxygen levels) is on the patient and working
  4. Check the patient’s medication allergies
  5. Review the risk of airway problems
  6. Review that appropriate equipment and assistance for them are available.
  7. Verify that intravenous lines, blood, and fluids are ready if the patient may lose blood.  (140)


The WHO checklists were evaluated in 8 hospitals around the world.  The rate of major complications in all 8 hospitals fell by 36% after introduction of the checklist.  Deaths fell 47%.  When they finished, the last question they asked the staff was, “If you were having an operation, would you want the checklist to be used?”  93% said yes.  (154-77)


“We have an opportunity before us, not just in medicine but in virtually any endeavor.  Even the most expert among us can gain from searching out the patterns of mistakes and failures and putting a few checks in place.” (158)


“We don’t like checklists.  They can be painstaking.  They’re not much fun.  But I don’t think the issue here is mere laziness.  There’s something deeper, more visceral going on when people walk away not only from saving lives but from making money.  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.” (173)


The final illustration shows how checklists and teamwork saved US Airways Flight 1549 that went down in the Hudson River with Captain Sully and his team.


“In a world in which success now requires large enterprises, teams of clinicians, high-risk technologies, and knowledge that outstrips any one person’s abilities, individual autonomy hardly seems the idea we should aim for. …  What is needed …is discipline.”  (183)


“We’re obsessed in medicine with having great components—the best drugs, the best devices, the best specialists—but pay little attention to how to make them fit together well.”  Optimizing parts is not a good route to system excellence.  “We don’t look for the patterns of our recurrent mistakes or devise and refine potential solutions for them.  But we could, and that is the ultimate point.”  “When we look closely, we recognize the same balls being dropped over and over, even by those of great ability and determination.  We know the patterns.  We see the costs.  It’s time to try something else.  Try a checklist.”   (184-86) 


“To my chagrin, however, [says the author] I have yet to get through a week in surgery without the checklist’s leading us to catch something we would have missed.”  (187) 


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