The Checklist Manifesto: How to Get Things Right

by Atul Gawande

First, “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.

it was as much a checklist study as a soap study. So I wondered: Could a checklist be our soap for surgical care—simple, cheap, effective, and transmissible?

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).

Even a modest checklist had the effect of distributing power.

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.

These misses are simple failures—perfect for a classic checklist. And as a result, all the researchers’ checklists included precisely specified steps to catch them. But the fourth killer—the unexpected

No, the more familiar and widely dangerous issue is a kind of silent disengagement, the consequence of specialized technicians sticking narrowly to their domains.

He knew this was trouble. His mind was completely sharp. But he didn’t seem scared.

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.

I realized the handbook was comprised not of one checklist but of scores of them. Each one was remarkably brief, usually just a few lines on a page in big, easy-to-read type. And each applied to a different situation. Taken together, they covered a vast range of flight scenarios.

There were the checks they do before starting the engines, before pulling away from the gate, before taxiing to the runway, and so on. In all, these took up just three pages. The rest of the handbook consisted of the “non-normal” checklists covering every conceivable emergency situation a pilot might run into: smoke in the cockpit, different warning lights turning on, a dead radio, a copilot becoming disabled, and engine failure, to name just a few. They addressed situations most pilots never encounter in their entire careers. But the checklists were there should they need them.

There are good checklists and bad, Boorman explained. 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 pro...

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.

no matter how careful we might be, no matter how much thought we might put in, a checklist has to be tested in the real world, which is inevitably more complicated than expected.

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

And by remaining swift and usable and resolutely modest, they are saving thousands upon thousands of lives.

The reason is more often that the necessary knowledge has not been translated into a simple, usable, and systematic form.

An inherent tension exists between brevity and effectiveness.

Nonetheless, the pattern confirmed what we’d understood: surgery is risky and dangerous wherever it is done.

the hospitals missed one of them in a startling two-thirds of patients, whether in rich countries or poor. That is how flawed and inconsistent surgical care routinely is around the world.

We needed the first groups using the checklist to have the seniority and patience to make the necessary modifications and not dismiss the whole enterprise.

In Tanzania, the hospital was two hundred miles of sometimes one-lane dirt roads from Dar es Salaam, and flooding during the rainy season cut off supplies—such as medications and anesthetic gases—often for weeks at a time. There were thousands

of surgery patients, but just five surgeons and four anesthesia staff. None of the anesthetists had a medical degree. The patients’ families supplied most of the blood for the blood bank, and when that wasn’t enough, staff members rolled up their sleeves. They conserved anesthetic supplies by administering mainly spinal anesthesia—injections of numbing medication directly into the spinal canal. They could do operations under spinal that I never conceived of. They saved and resterilized their surgical gloves, using them over and over until holes appeared. They even made their own surgical gauze, the nurses and anesthesia staff sitting around an old wood table at teatime each afternoon cutting bolts of white cotton cloth to size for the next day’s cases.

However straightforward the checklist might appear, if you are used to getting along without one, incorporating it into the routine is not always a smooth process.

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.

Then we asked the staff one more question. “If you were having an operation,” we asked, “would you want the checklist to be used?” A full 93 percent said yes.

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.

Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is.

It is a single, broad-brush device intended to catch a few problems common to all operations, and we surgeons could build on it to do even more. We could adopt, for example, specialized checklists for hip replacement procedures, pancreatic operations, aortic aneurysm repairs, examining each of our major procedures for their most common avoidable glitches and incorporating checks to help us steer clear of them. We could even devise emergency checklists, like aviation has, for nonroutine situations—such as the cardiac arrest my friend John described in which the doctors forgot that an overdose of potassium could be a cause.

And it is true well beyond medicine. The opportunity is evident in many fields—and so also is the resistance.

Neuroscientists have found that the prospect of making money stimulates the same primitive reward circuits in the brain that cocaine does.

They focus on dispassionate analysis, on avoiding both irrational exuberance and panic.

Yet no matter how objective he tried to be about a potentially exciting investment, he said, he found his brain working against him, latching onto evidence that confirmed his initial hunch and dismissing the signs of a downside. It’s what the brain does.

“I am not Warren,” he said. “I don’t have a 300 IQ.” He needed an approach that could work for someone with an ordinary IQ. So he devised a written checklist.

So Pabrai made a list of mistakes he’d seen—ones Buffett and other investors had made as well as his own. It soon contained dozens of different mistakes, he said. Then, to help him guard against them, he devised a matching list of checks—about seventy in all.

he enumerated the errors known to occur at any point in the investment process—during the research phase, during decision making, during execution of the decision, and even in the period after making an investment when one should be monitoring for problems. He then designed detailed checklists to avoid the errors, complete with clearly identified pause points at which he and his investment team would run through the items.

“It’s easy to hide in a statement. It’s hard to hide between statements,”

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.

“When surgeons make sure to wash their hands or to talk to everyone on the team”—he’d seen the surgery checklist—“they improve their outcomes with no increase in skill. That’s what we are doing when we use the checklist.”

in a period of enormous volatility the checklist gave his team at least one additional and unexpected edge over others: efficiency.

When he first introduced the checklist, he assumed it would slow his team down, increasing the time and work required for their

investment decisions. He was prepared to pay that price. The benefits of making fewer mistakes seemed obvious. And in fact, using the checklist did increase the up-front work time. But to his surprise, he found they were able...

With the checklist in place, however, he observed that he could move through investment decisions far faster and more methodically.

What makes these investors’ experiences striking to me is not merely their evidence that checklists might work as well in finance as they do in medicine. It’s that here, too, they have found takers slow to come.

most investors were either Art Critics or Sponges—intuitive decision makers instead of systematic analysts. Only one in eight took the Airline Captain approach. Now,

And by adhering to this discipline—by taking just those few short minutes—they not only made sure the plane was fit to travel but also transformed themselves from individuals into a team, one systematically prepared to handle whatever came their way.

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