The Checklist Manifesto: How to Get Things Right

by Atul Gawande

“Your mind doesn’t think of a bayonet in San Francisco,”

The anesthesiologist had used the wrong concentration of potassium, a concentration one hundred times higher than he’d intended. He had, in other words, given the patient a lethal overdose of potassium.

control. But John’s stories got me thinking about what is really in our control and what is not.

“necessary fallibility”—some

The first is ignorance—we may err because science has given us only a partial understanding of the world and how it works.

The second type of failure the philosophers call ineptitude—because in these instances the knowledge exists, yet

we fail to apply it correctly.

Getting the steps right is proving brutally hard, even if you know them.

simple administrative errors, like missed calendar dates and clerical screw ups, as well as errors in applying the law. You see it in flawed software design, in foreign intelligence failures, in our tottering banks—in fact, in almost any endeavor requiring mastery of complexity and of large amounts of knowledge.

But if the knowledge exists and is not applied correctly, it is difficult not to be infuriated.

ineptitude.

Every day there is more and more to manage and get right and learn. And defeat under conditions of complexity occurs far more often despite great effort rather than from a lack of it. That’s why the traditional solution in most professions has not been to punish failure but instead to encourage more experience and training.

And if what we are missing when we fail is individual skill, then what is needed is simply more training and practice.

Avoidable failures are common and persis tent, not to mention demoralizing

and frustrating, across many fields—from medicine to finance, business to government.

And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliabl...

That means we need a different strategy for overcoming failure, one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our inevitable human inadequacies. And there is such a strategy—though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us...

It is a che...

*Identifying details were changed at J...

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 orchestra...

But extreme complexity is the rule for almost everyone.

critical care,

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.

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.

While doing all this, Hill had forgotten to release a new locking mechanism on the elevator and rudder controls. The Boeing model was deemed, as a newspaper put it, “too much airplane for one man to fly.”

What they decided not to do was almost as interesting as what they actually did. They did not require Model 299 pilots to undergo longer training. It was hard to imagine having more experience and expertise than Major Hill, who had been the air corps’ chief of flight testing. Instead, they came up with an ingeniously simple approach: they created a pilot’s checklist. Its mere existence indicated how far aeronautics had advanced. In the early years of flight, getting an aircraft into the air might have been nerve-racking but it was hardly complex. Using a checklist for takeoff

would no more have occurred to a pilot than to a driver backing a car out of the garage. But flying this new plane was too complicated to be left to the memory of any one person, however expert.

The test pilots made their list simple, brief, and to the point—short enough to fit on an index card, with step-by-step checks for takeoff, flight, landing, and taxiing. It had the kind of stuff that all pilots know to do. They check that the brakes are released, that the instruments are set, that the door and windows are closed, that the elevator controls are unlocked—dumb stuff. You wouldn’t think it would make that much difference. But wi...

Yet it is far from obvious that something as simple as a checklist could be of substantial help. We may admit that errors and oversights occur—even devastating ones. But we believe our jobs are too complicated to reduce to a checklist. Sick people, for instance, are phenomenally more various than airplanes. A study of forty-one thousand trauma patients in the state of

Pennsylvania—just trauma patients—found that they had 1,224 different injury-related diagnoses in 32,261 unique combinations. That’s like having 32,261 kinds of airplane to land. Mapping out the proper steps for every case is not possible, and physicians have been skeptical that a piece of paper with a bunch of little boxes would improve matters.

Comprised of four physiological data points—body temperature, pulse, blood pressure, and respiratory rate—they give health professionals a basic picture of how sick a person is.

Faulty memory and distraction are a particular danger in what engineers call all-or-none processes: whether running to the store to buy ingredients for a cake, preparing an airplane for takeoff, or evaluating a sick person in the hospital, if you miss just one key thing, you might as well not have made the effort at all.

Checklists seem to provide protection against such failures. They remind us of the minimum necessary steps and make them explicit.

The routine recording of the four vital signs did not become the norm in Western hospitals until the 1960s, when nurses embraced the idea. They designed their patient charts and forms to include the signs, essentially creating a checklist for themselves.

In 2001, though, a critical care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give a doctor checklist a try. He didn’t attempt to make the checklist encompass everything ICU teams might need to do in a day. He designed it to tackle just one of their hundreds of potential tasks, the one that nearly killed Anthony DeFilippo: central line infections.

On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting in a central line. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a mask, hat, sterile gown, and gloves, and (5) put a sterile dressing over the insertion site once the line is in. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist

for something so obvious. Still, Pronovost asked the nurses in his ICU to observe the doctors for a month as they put lines into patients and record how often they carried out each step. In more...

The next month, he and his team persuaded the Johns Hopkins Hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask the doctors each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder (“Um, did you forget to put on your mask, doctor?”) to...

aren’t sure whether this is their place or whether a given measure is worth a confrontation. (Does it really matter whether a patient’s legs are draped for a line going into the chest?) The new rule made it clear: if doctors didn’t follow every step,...

the ten-day line-infection rate went from 11 percent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths and saved two million dollars in costs.

The researchers 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.

Checklists, he found, established a higher standard of baseline performance.

Pronovost is routinely described by colleagues as “brilliant,” “inspiring,” a “genius.” He has an M.D. and a Ph.D. in public health from Johns Hopkins and

is trained in emergency medicine, anesthesiology, and critical care medicine. But, really, does it take all that to figure out what anyone who has made a to-do...

Tom Piskorowski, one of the ICU physicians, told me his reaction: “Forget the paperwork. Take care of the patient.”

The successes have been sustained for several years now—all because of a stupid little checklist.

Markus Thalmann,