The Checklist Manifesto: How to Get Things Right

by Atul Gawande

The researchers learned that about half the time the staff did not know one another’s names. When they did, however, the communications ratings jumped significantly.

The investigators at Johns Hopkins and elsewhere had also observed that when nurses were given a chance to say their names and mention concerns at the beginning of a case, they were more likely to note problems and offer solutions. The researchers called it an “activation phenomenon.” Giving people a chance to say something at the start seemed to activate their sense of participation and responsibility and their willingness to speak up.

the checklist led the staff to catch a paperwork error that had them planning for a thoracotomy, an open-chest procedure with a huge front-to-back wound, when what the patient had come in for was actually a thoracoscopy, a videoscope procedure done through a quarter-inch incision.

But by the end of the Geneva conference, we had agreed that a safe surgery checklist was worth testing on a larger scale.

A working group took the different checklists that had been tried and condensed them into a single one. It had three “pause points,” as they are called in aviation—three points at which the team must stop to run through a set of checks before proceeding.

The checklist was too long. It was unclear. And past a certain point, it was starting to feel like a distraction from the person we had on the table. By the end of the day, we had stopped using the checklist. Forget making this work around the world. It wasn’t even working in one operating room.

Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat the people using the tools as dumb and try to spell out every single step. They turn people’s brains off rather than turn them on.

Good checklists, on the other hand, are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything—a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps—the ones that even the highly skilled professionals using them could miss. Good checklists are, above all, practical.

The power of checklists is limited, Boorman emphasized. They can help experts remember how to manage a complex process or configure a complex machine. They can make priorities clearer and prompt people to function better as a team. By ...

Pilots nonetheless turn to their checklists for two reasons. First, they are trained to do so. They learn from the beginning of flight school that their memory and judgment are unreliable and that lives depend on their recognizing that fact. Second, the checklists have proved their worth—they work. However much pilots are taught to trust their procedures more than their instincts, that doesn’t mean they will do so blindly. Aviation checklists are by no means perfect. Some have been found confusing or unclear or flawed. Nonetheless, they have earned pilots’ faith. Face-to-face with catastrophe, they are astonishingly willing to turn to their checklists.

When you’re making a checklist, Boorman explained, you have a number of key decisions. You must define a clear pause point at which the checklist is supposed to be used (unless the moment is obvious, like when a warning light goes on or an engine fails). You must decide whether you want a DO-CONFIRM checklist or a READ-DO checklist. With a DO-CONFIRM checklist, he said, team members perform their jobs from memory and experience, often separately. But then they stop. They pause to run the checklist and confirm that everything that was supposed to be done was done. With a READ-DO checklist, on the other hand, people carry out the tasks as they check them off—it’s more like a recipe. So for any new checklist created from scratch, you have to pick the type that makes the most sense for the situation.

The checklist cannot be lengthy. A rule of thumb some use is to keep it to between five and nine items, which is the limit of working memory.

But after about sixty to ninety seconds at a given pause point, the checklist often becomes a distraction from other things. People start “shortcutting.” Steps get missed. So you want to keep the list short by focusing on what he called “the killer items”—the steps that are most dangerous to skip and sometimes overlooked nonetheless.

The wording should be simple and exact, Boorman went on, and use the familiar language of the profession. Even the look of the checklist matters. Ideally, it should fit on one page. It should be free of clutter and unnecessary colors. It should use both uppercase and lowercase text for ease of reading. (He went so far as to recommend using a sans serif type like Helvetica.)

First drafts always fall apart, he said, and one needs to study how, make changes, and keep testing until the checklist works consistently.

It is common to misconceive how checklists function in complex lines of work. They are not comprehensive how-to guides, whether for building a skyscraper or getting a plane out of trouble. They are quick and simple tools aimed to buttress the skills of expert professionals. And by remaining swift and usable and resolutely modest, they are saving thousands upon thousands of lives.

we rarely investigate our failures. Not in medicine, not in teaching, not in the legal profession, not in the financial world, not in virtually any other kind of work where the mistakes do not turn up on cable news. 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.

Sometimes, though, failures are investigated. We learn better ways of doing things. And then what happens? Well, the findings might turn up in a course or a seminar, or they might make it into a professional journal or a textbook. In ideal circumstances, we issue some inch-thick set of guidelines or a declaration of standards. But getting the word out is far from assured, and incorporating the changes often takes years.

Within about a month of the recommendations becoming available, pilots had the new checklist in their hands—or in their cockpit computers. And they used it.

An inherent tension exists between brevity and effectiveness. Cut too much and you won’t have enough checks to improve care. Leave too much in and the list becomes too long to use.

All we’d done was give them a one-page, nineteen-item list and shown them how to use it.

The final results showed that the rate of major complications for surgical patients in all eight hospitals fell by 36 percent after introduction of the checklist. Deaths fell 47 percent. The results had far outstripped what we’d dared to hope for, and all were statistically highly significant. Infections fell by almost half. The number of patients having to return to the operating room after their original operations because of bleeding or other technical problems fell by one-fourth. Overall, in this group of nearly 4,000 patients, 435 would have been expected to develop serious complications based on our earlier observation data. But instead just 277 did. Using the checklist had spared more than 150 people from harm—and 27 of them from death.

In every site, introduction of the checklist had been accompanied by a substantial reduction in complications. In seven out of eight, it was a double-digit percentage drop.

More than 250 staff members—surgeons, anesthesiologists, nurses, and others—filled out an anonymous survey after three months of using the checklist. In the beginning, most had been skeptical. But by the end, 80 percent reported that the checklist was easy to use, did not take a long time to complete, and had improved the safety of care. And 78 percent actually observed the checklist to have prevented an error in the operating room.

The checklist doesn’t tell him what to do, he explained. It is not a formula. But the checklist helps him be as smart as possible every step of the way, ensuring that he’s got the critical information he needs when he needs it, that he’s systematic about decision making, that he’s talked to everyone he should. With a good checklist in hand, he was convinced he and his partners could make decisions as well as human beings are able. And as a result, he was also convinced they could reliably beat the market.

The fear people have about the idea of adherence to protocol is rigidity. They imagine mindless automatons, heads down in a checklist, incapable of looking out their windshield and coping with the real world in front of them. But what you find, when a checklist is well made, is exactly the opposite. The checklist gets the dumb stuff out of the way, the routines your brain shouldn’t have to occupy itself with

Nonetheless, even with fortune on their side, there remained every possibility that 155 lives could have been lost that day. But what rescued them was something more exceptional, difficult, crucial, and, yes, heroic than flight ability. The crew of US Airways Flight 1549 showed an ability to adhere to vital procedures when it mattered most, to remain calm under pressure, to recognize where one needed to improvise and where one needed not to improvise. They understood how to function in a complex and dire situation. They recognized that it required teamwork and preparation and that it required them long before the situation became complex and dire. This was what was unusual. This is what it means to be a hero in the modern era. These are the rare qualities that we must understand are needed in the larger world.

expectation of selflessness: that we who accept responsibility for others—whether we are doctors, lawyers, teachers, public authorities, soldiers, or pilots—will place the needs and concerns of those who depend on us above our own.

expectation of skill: that we will aim for excellence in our knowledge and expertise.

expectation of trustworthiness: that we will be responsible in our personal beha...

Aviators, however, add a fourth expectation, discipline: discipline in following prudent procedure an...

Discipline is hard—harder than trustworthiness and skill and perhaps even than selflessness. We are by nature flawed and inconstant creatures. We can’t even keep from snacking between meals. 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.

To be sure, checklists must not become ossified mandates that hinder rather than help. Even the simplest requires frequent revisitation and ongoing refinement. Airline manufacturers put a publication date on all their checklists, and there is a reason why—they are expected to change with time. 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.

Without question, technology can increase our capabilities. But there is much that technology cannot do: deal with the unpredictable, manage uncertainty, construct a soaring building, perform a lifesaving operation. In many ways, technology has complicated these matters. It has added yet another element of complexity to the systems we depend on and given us entirely new kinds of failure to contend with.

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. Berwick notes how wrongheaded this approach is. “Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence,” he says.

We don’t study routine failures in teaching, in law, in government programs, in the financial industry, or elsewhere. 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. We are all plagued by failures—by missed subtleties, overlooked knowledge, and outright errors.

I had better be using it myself. But in my heart of hearts—if you strapped me down and threatened to take out my appendix without anesthesia unless I told the truth—did I think the checklist would make much of a difference in my cases? No. In my cases? Please. To my chagrin, however, I have yet to get through a week in surgery without the checklist’s leading us to catch something we would have missed.

No matter how routine an operation is, the patients never seem to be. But with the checklist in place, we have caught unrecognized drug allergies, equipment problems, confusion about medications, mistakes on labels for biopsy specimens going to pathology. (“No, that one is from the right side. This is the one from the left side.”) We’ve made better plans and been better prepared for patients. I am not sure how many important issues would have slipped by us without the checklist and actually caused harm. We were not bereft of defenses. Our usual effort to be vigilant and attentive might have caught some of the problems. And those we didn’t catch may never have gone on to hurt anyone.

We came into the room as strangers. But when the knife hit the skin, we were a team.