The Checklist Manifesto: How to Get Things Right

by Atul Gawande

1970s, the philosophers Samuel Gorovitz and Alasdair MacIntyre published a short essay on the nature of human fallibility

The question they sought to answer was why we fail at what we set out to do in the world.

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

ineptitude—because in these instances the knowledge exists, yet we fail to apply it correctly.

traditional solution in most professions has not been to punish failure but instead to encourage more experience and training.

the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably.

World Health Organization’s international classification of diseases has grown to distinguish more than thirteen thousand different diseases, syndromes, and types of injury—

But for each condition the steps are different and they are almost never simple. Clinicians now have at their disposal some six thousand drugs and four thousand medical and surgical procedures, each with different requirements, risks, and considerations. It is a lot to get right.

body temperature, pulse, blood pressure, and respiratory rate—

fallibility of human memory and attention,

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.

These checklists accomplished what checklists elsewhere have done, Pronovost observed. They helped with memory recall and clearly set out the minimum necessary steps in a process.

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

Some physicians were offended by the suggestion that they needed checklists.

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.

power of communication. They didn’t believe in the wisdom of the single individual,

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.

He showed me an application called Clash Detective that ferreted out every instance in which the different specs conflicted with one another or with building regulations.

There’s yet another program, called ProjectCenter, that allows anyone who has found a problem—even a frontline worker—to e-mail all the relevant parties, track progress, and make sure a check is added to the schedule to confirm that everyone has talked and resolved the matter.

major advance in the science of construction over the last few decades has been the perfection of tracking and communication.

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.

By 2004, surgeons were performing some 230 million major operations annually—one for every twenty-five human beings on the planet—and the numbers have likely continued to increase since then.

There was also a notable correlation between teamwork scores and results for patients—the greater the improvement in teamwork, the greater the drop in complications.