The Checklist Manifesto: How to Get Things Right

by Atul Gawande

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.

Medicine has become the art of managing extreme complexity—and a test of whether such complexity can, in fact, be humanly mastered.

If we cannot cure the disease, then we can usually reduce the harm and misery it causes.

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.

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.

You really can’t do everything anymore.

The knowledge exists. But however supremely specialized and trained we may have become, steps are still missed. Mistakes are still made.

Multiple fields, in other words, have become too much airplane for one person to fly. 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.

fallibility of human memory and attention, especially when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events.

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.

people can lull themselves into skipping steps even when they remember them. In complex processes, after all, certain steps don’t always matter.

“This has never been a problem before,” people say. Until one day it is. Checklists seem to provide protection against such failures. They remind us of the minimum necessary steps and make them explicit. They not only offer the possibility of verification but also instill a kind of discipline of higher performance.

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 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.

Complex problems are ones like raising a child. Once you learn how to send a rocket to the moon, you can repeat the process with other rockets and perfect it. One rocket is like another rocket. But not so with raising a child, the professors point out. Every child is unique.

another feature of complex problems: their outcomes remain highly uncertain.

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?

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.

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

although buildings are now more complex and sophisticated than ever in history, with higher standards expected for everything from earthquake proofing to energy efficiency, they take a third less time to build than they did when he started his career. The checklists work.

The philosophy is that you push the power of decision making out to the periphery and away from the center. You give people the room to adapt, based on their experience and expertise. All you ask is that they talk to one another and take responsibility. That is what works.

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.

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. People need room to act and adapt. Yet they cannot succeed as isolated individuals, either—that is anarchy. Instead, they require a seemingly contradictory mix of freedom and expectation—expectation to coordinate, for example, and also to measure progress toward common goals.

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.

The volume of surgery had grown so swiftly that, without anyone’s quite realizing, it has come to exceed global totals for childbirth—only with a death rate ten to one hundred times higher. Although most of the time a given procedure goes just fine, often it doesn’t: estimates of complication rates for hospital surgery range from 3 to 17 percent. While incisions have gotten smaller and recoveries have gotten quicker, the risks remain serious. Worldwide, at least seven million people a year are left disabled and at least one million dead—a level of harm that approaches that of malaria, tuberculosis, and other traditional public health concerns.

Improvement in global economic conditions in recent decades had produced greater longevity and therefore a greater need for essential surgical services—for people with cancers, broken bones and other traumatic injuries, complications during child delivery, major birth defects, disabling kidney stones and gallstones and hernias. Although there remained some two billion people, especially in rural areas, without access to a surgeon, health systems in all countries were now massively increasing the number of surgical procedures performed. As a result, the safety and quality of that care had become a major issue everywhere.

medical officer in his forties from western Ghana, where cocoa growing and gold mining had brought a measure of prosperity, told of the conditions in his district hospital. No surgeon was willing to stay, he said. Ghana was suffering from a brain drain, losing many of its highest skilled citizens to better opportunities abroad. He told us his entire hospital had just three medical officers—general physicians with no surgical training.

“You must understand,” he said. “I manage everything. I am the pediatrician, obstetrician, surgeon, everything.” He had textbooks and a manual of basic surgical techniques. He had an untrained assistant who had learned how to give basic anesthesia. His hospital’s equipment was rudimentary. The standards were poor. Things sometimes went wrong. But he was convinced doing something was better than doing nothing at all.

An anesthesiologist from India chimed in, tracing problems with anesthesia to the low respect most surgeons accord anesthetists. In her country, she said, they shout anesthetists down and disregard the safety issues that her colleagues raise. Medical students see this and decide not to go into anesthesiology. As a result, the most risky part of surgery—anesthesia—is done by untrained people far more often than the surgery itself.

Each percentage point, after all, represented millions left disabled or dead. Studies in the United States alone had found that at least half of surgical complications were preventable.

Down in the basement, while taking a shortcut between buildings, I saw pallet after pallet of two-hundred-page guideline books from other groups that had been summoned to make their expert pronouncements. There were guidelines stacked waist-high on malaria prevention, HIV/AIDS treatment, and influenza management, all shrink-wrapped against the gathering dust. The standards had been carefully written and were, I am sure, wise and well considered. Some undoubtedly raised the bar of possibility for achievable global standards. But in most cases, they had at best trickled out into the world. At the bedsides of patients in Bangkok and Brazzaville, Boston and Brisbane, little had changed.

Sewage ran in the streets. Chronic poverty and food shortages left 30 to 40 percent of the children malnourished. Virtually all drinking water sources were contaminated. One child in ten died before age five—usually from diarrhea or acute respiratory infections. The roots of these problems were deep and multifactorial. Besides inadequate water and sewage systems, illiteracy played a part, hampering the spread of basic health knowledge. Corruption, political instability, and bureaucracy discouraged investment in local industry that might provide jobs and money for families to improve their conditions. Low global agriculture prices made rural farming life impossible, causing hundreds of thousands to flock to the cities in search of work, which only increased the crowding. Under these circumstances, it seemed unlikely that any meaningful improvement in the health of children could be made without a top-to-bottom reinvention of government and society.

Luby learned that Procter & Gamble, the consumer product conglomerate, was eager to prove the value of its new antibacterial Safeguard soap. So despite his colleagues’ skepticism, he persuaded the company to provide a grant for a proper study and to supply cases of Safeguard both with and without triclocarban, an antibacterial agent. Once a week, field-workers from HOPE fanned out through twenty-five randomly chosen neighborhoods in the Karachi slums distributing the soap, some with the antibacterial agent and some without. They encouraged people to use it in six situations: to wash their bodies once daily and to wash their hands every time they defecated, wiped an infant, or were about to eat, prepare food, or feed it to others. The field-workers then collected information on illness rates among children in the test neighborhoods, as well as in eleven control neighborhoods, where no soap was distributed.

Luby and his team reported their results in a landmark paper published in the Lancet in 2005. Families in the test neighborhoods received an average of 3.3 bars of soap per week for one year. During this period, the incidence of diarrhea among children in these neighborhoods fell 52 percent compared to that in the control group, no matter which soap was used. The incidence of pneumonia fell 48 percent. And the incidence of impetigo, a bacterial skin infection, fell 35 percent. These were stunning results. And they were achieved despite the illiteracy, the poverty, the crowding, and even the fact that, however much soap they used, people were still drinking and washing with contaminated water.

Ironically, Luby said, Procter & Gamble considered the study something of a disappointment. His research team had found no added benefit from having the antibacterial agent in the soap. Plain soap proved just as effective. Against seemingly insupe...

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 households in both the test and the control neighborhoods: At the start of the s...

“We removed the economic restraint on purchasing soap. People say soap is cheap and most households have soap. But we wanted people to wash a lot. And people are quite poor. So we removed that as a barrier.” Second, and just as important, the project managed to make soap use more systematic.

The soap itself was also a factor. “It was really nice soap,” he pointed out. It smelled good and lathered better than the usual soap people bought. People liked washing with it. “Global multinational corporations are really focused on having a good consumer experience, which sometimes public health people are not.” Lastly, people liked receiving the soap. The public health field-workers were bringing them a gift rather than wagging a finger. And with the gift came a few basic ideas that would improve their lives and massively reduce disease.

In 2005, Columbus Children’s Hospital examined its records and found that more than one-third of its appendectomy patients failed to get the right antibiotic at the right time. Some got it too soon. Some got it too late. Some did not receive an antibiotic at all. It seems dumb. How hard could this be? Even people in medicine assume we get this kind of simple task right 100 percent of the time. But in fact we don’t. With all the flurry of things that go on when a patient is wheeled into an operating room, this is exactly the sort of step that can be neglected.

The hospital’s director of surgical administration, who happened to be not only a pediatric cardiac surgeon but also a pilot, decided to take the aviation approach. 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).

The surgical director measured the effect on care. After three months, 89 percent of appendicitis patients got the right antibiotic at the right time. After ten months, 100 percent did. The checklist had become habitual—and it had also become clear that team members could hold up an operation until the necessary steps were completed.

The checklist also included what they called a “team briefing.” The team members were supposed to stop and take a moment simply to talk with one another before proceeding—about how long the surgeon expected the operation to take, how much blood loss everyone should be prepared for, whether the patient had any risks or concerns the team should know about.

researchers have observed that team members are commonly not all aware of a given patient’s risks, or the problems they need to be ready for, or why the surgeon is doing the operation. In one survey of three hundred staff members as they exited the operating room following a case, one out of eight reported that they were not even sure about where the incision would be until the operation started.

although 64 percent of the surgeons rated their operations as having high levels of teamwork, just 39 percent of anesthesiologists, 28 percent of nurses, and 10 percent of anesthesia residents did.

the more familiar and widely dangerous issue is a kind of silent disengagement, the consequence of specialized technicians sticking narrowly to their domains. “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.

Teamwork may just be hard in certain lines of work. Under conditions of extreme complexity, we inevitably rely on a division of tasks and expertise—

we need them to see their job not just as performing their isolated set of tasks well but also as helping the group get the best possible results. This requires finding a way to ensure that the group lets nothing fall between the cracks and also adapts as a team to whatever problems might arise.

People don’t always get it—really feel the urgency of the patient’s condition.

Their insistence that people talk to one another about each case, at least just for a minute before starting, was basically a strategy to foster teamwork—a kind of team huddle, as it were. So was another step that these checklists employed, one that was quite unusual in my experience: surgical staff members were expected to stop and make sure that everyone knew one another’s names.