The Checklist Manifesto: How to Get Things Right

by Atul Gawande

I asked Thalmann how the hospital had managed such a complicated rescue.

He took a close look at the case records. Preparation, he determined, was the chief difficulty. Success required having an array of people and equipment at the ready—trauma surgeons, a cardiac anesthesiologist, a cardiothoracic surgeon, bioengineering support staff, a cardiac perfusionist, operating and critical care nurses, intensivists. Almost routinely, someone or something was missing.

He tried the usual surgical approach to remedy this—yelling at everyone to get their act together. But still they had no saves. So he and a couple of colleagues decided to try something new. They made a checklist.

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.

But they presumably have limits, as well. So a key step is to identify which kinds of situations checklists can hel...

the simple, the complicated, and the complex.

The value of checklists for simple problems seems self-evident. But can they help avert failure when the problems combine everything from the simple to the complex?

First, how could they be sure that they had the right knowledge in hand? Second, how could they be sure that they were applying this knowledge correctly?

columns were supposed to go. “A building is like a body,” he said. It has a skin. It has a skeleton. It has a vascular system—the plumbing. It has a breathing system—the ventilation. It has a nervous system—the wiring. All together, he explained, projects today involve some sixteen different trades.

No matter how complex the problems he faced in designing that first shopping mall roof, he very quickly understood that he had no margin for error.

He tried to explain how he and his colleagues made sure that all those people were doing their work correctly, that the building would come together properly,

despite the enormous number of considerations—and despite the fact that he could not possibly understand the particulars of most of the tasks involved. But I didn’t really get his explanation until he brought me to the main conference room. There, on the walls around a big white oval table, hung sheets of butcher-block-size printouts of what were, to my surprise, checklists.

the tilting of the upper floors.

“submittal schedule.”

communication tasks.

The submittal schedule specified, for instance, that by the end of the month the contractors, installers, and elevator engineers had to review the condition of the elevator cars traveling up to the tenth floor. The elevator cars were factory constructed and tested. They were installed by experts. But it was not assumed that they would work perfectly. Quite the opposite. The assumption was that anything could go wrong, anything could get missed. What? Who knows? That’s the nature of

complexity. But it was also assumed that, if you got the right people together and had them take a moment to talk things over as a team rather than as individuals, serious problems could be identified and averted.

In the face of the unknown—the always nagging uncertainty about whether, under complex circumstances, things will really be okay—the builders trusted in the power of communication. They didn’t believe in the wisdom of the single individual, of even an experienced engineer. They believed in the wisdom of the group, the wisdom of making sure that multiple pairs of eyes were on a problem and then letting the watchers decide what to do.

Man is fallible, but maybe men are less so.

“tuned mass damper.”

They trust instead in one set of checklists to make sure that simple steps are not missed or skipped and in another set to make sure that everyone talks through and resolves all the hard and unexpected problems.

“The biggest cause of serious error in this business is a failure of communication,” O’Sullivan told me.

In response to risk, most authorities tend to centralize power and decision making. That’s usually what checklists are about—dictating instructions to the workers below to ensure they do things the way we want. Indeed, the

first building checklist I saw, the construction schedule on the right-hand wall of O’Sullivan’s conference room, was exactly that. It spelled out to the tiniest detail every critical step the tradesmen were expected to follow and when—which is logical if you’re confronted with simple and routine problems; you want the forcing function.

“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.”

No, the real lesson is that under conditions of true complexity—where the knowledge required exceeds that of any individual and unpredictability reigns—efforts to dictate every step from the center will fail.

That routine requires balancing a number of virtues: freedom and discipline, craft and protocol, specialized ability and group collaboration. And for checklists to help achieve that balance, they have to take two almost opposing forms.

They supply a set of checks to ensure the stupid but critical stuff is not overlooked, and they supply another set of checks to ensure people talk and coordinate and accept responsibility while nonetheless being left the power to manage the nuances and unpredictabilities the best they know how.

under conditions of complexity, not only are checklists a help, they are required for success. There must always be room for judgment, but judgment aided—and even enhanced—by procedure.

Adams is self-taught. An anthropology major at Brown University, she never went to culinary school. “But I had a thing for food,” as she puts it, and she went

to work in restaurants, learning her way from chopping onions to creating her own style of cooking.

I understood perfectly well how the Burger Kings and Taco Bells of the world operate.

First there was the recipe—the most basic checklist of all. Every dish had one. The recipes were typed out, put in clear plastic sleeves, and placed at each station. Adams was religious about her staff’s using them. Even

for her, she said, “following the recipe is essential to making food of consistent quality over time.”

The staff didn’t always love following the recipes. You make the creamed corn a few hundred times and you believe you have it down. But that’s when things begin to slip, Adams said.

“Fire” meant cook it now. “On hold” meant it was a second course.

“pow wow.”

There remained plenty of sources of uncertainty and imperfection: a soup might be plated too early and allowed to cool, a quail might have too little sauce, a striped bass might come off the grill too dry. So Adams had one final check in place.

Every plate had to be reviewed by either her or the sous chef before it left the kitchen for the dining room. They made sure the food looked the way it should, checked it against the order ticket, gave it a sniff or, with a clean spoon, maybe even a taste.

There seemed no field or profession where checklists might not help. And that might even include my own.

“Oh, sorry. I thought you were supposed to be some kind of expert on patient safety in surgery. My mistake.”

work of Dr. John Snow famously tracing a deadly 1854 London cholera outbreak to water in a public well. When the disease struck a London neighborhood that summer, two hundred

They involved simple interventions—a vaccine, the removal of a pump handle. The effects were carefully measured. And the interventions proved to have widely transmissible benefits—what business types would term a large ROI (return on investment) or what Archimedes would have called, merely, leverage.

projects.” So instead, he said, he looked for low-tech solutions. In this case, the solution he came up with was so humble it seemed laughable to his colleagues. It was soap.

The secret, he pointed out to me, was that the soap was more than soap. It was a behavior-change delivery vehicle. The researchers hadn’t just handed out Safeguard, after all. They also gave out instructions—on leaflets and in person—explaining the six situations in

which people should use it. This was essential to the difference they made. When one looks closely at the details of the Karachi study, one finds a striking statistic about the house -holds in both the test and the control neighborhoods: At the start of the study, the average number of bars of soap house holds used was not zero. It was two bars per week. In other words, they already had soap.

He designed a preincision “Cleared for Takeoff” checklist that he put on a whiteboard in each of the operating rooms. It was really simple. There was a check box for the nurse to verbally confirm with the team that they had the correct patient and the correct side of the body planned for surgery—something teams are supposed to verify in any case. And there was a further check box to confirm that the antibiotics were given (or else judged unnecessary, which they can be for some operations).

Surgery has, essentially, four big killers wherever it is done in the world: infection, bleeding, unsafe anesthesia, and what can only be called the unexpected. For the first three, science and experience have given us some straightforward and valuable preventive measures we think we consistently follow but don’t. These misses are simple failures—perfect for a classic checklist.

“That’s not my problem” is possibly the worst thing people can think, whether they are starting an operation, taxiing an airplane full of passengers down a runway, or building a thousand-foot-tall skyscraper. But in medicine, we see it all the time. I’ve seen it in my own operating room.