The Checklist Manifesto: How to Get Things Right

by Atul Gawande

Except no one remembered to ask the patient or the emergency medical technicians what the weapon was.

“Your mind doesn’t think of a bayonet in San Francisco,” John could only say.

The anesthesiologist had used the wrong concentration of potassium, a concentration one hundred times higher than he’d intended. He had, in other words, given the patient a lethal overdose of potassium.

Even enhanced by technology, our physical and mental powers are limited. Much of the world and universe is—and will remain—outside our understanding and control.

The second type of failure the philosophers call ineptitude—because in these instances the knowledge exists, yet we fail to apply it correctly.

What is the likelihood that all this will actually occur within ninety minutes in an average hospital? In 2006, it was less than 50 percent.

Getting the steps right is proving brutally hard, even if you know them.

You see it in flawed software design, in foreign intelligence failures, in our tottering banks—in fact, in almost any endeavor requiring mastery of complexity and of large amounts of knowledge.

if the knowledge exists and is not applied correctly, it is difficult not to be infuriated.

One needs practice to achieve mastery, a body of experience before one achieves real success.

Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields—from medicine to finance, business to government. And the reason is increasingly evident: 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.

The ninth edition of the World Health Organization’s international classification of diseases has grown to distinguish more than thirteen thousand different diseases, syndromes, and types of injury—more than thirteen thousand different ways, in other words, that the body can fail.

On a hectic day, when you’re running two hours behind and the people in the waiting room are getting irate, you may not take the time to record the precise diagnostic codes in the database.

Remarkably, the nurses and doctors were observed to make an error in just 1 percent of these actions—but that still amounted to an average of two errors a day with every patient.

Each of his organ systems, including his brain, was shutting down.

It was as if we had gained a steering wheel and a few gauges and controls, but on a runaway 18-wheeler hurtling down a mountain.

Line infections are so common that they are considered a routine complication.

Weak and debilitated, he lost his limousine business and his home, and he had to move in with his sister.

Here, then, is the fundamental puzzle of modern medical care: you have a desperately sick patient and in order to have a chance of saving him you have to get the knowledge right and then you have to make sure that the 178 daily tasks that follow are done correctly—despite some monitor’s alarm going off for God knows what reason, despite the patient in the next bed crashing, despite a nurse poking his head around the curtain to ask whether someone could help “get this lady’s chest open.” There is complexity upon complexity.

Moreover, research has consistently showed that at least half our deaths and major complications are avoidable.

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

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.

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.

For a year afterward, Pronovost and his colleagues monitored what happened. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from 11 percent to zero.

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

Within the first three months of the project, the central line infection rate in Michigan’s ICUs decreased by 66 percent.

Most ICUs—including the ones at Sinai-Grace Hospital—cut their quarterly infection rate to zero. Michigan’s infection rates fell so low that its average ICU outperformed 90 percent of ICUs nationwide.

The successes have been sustained for several years now—all because of a stupid little checklist.

“forcing functions”: relatively straightforward solutions that force the necessary behavior—solutions like checklists.

Man is fallible, but maybe men are less so.

“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. People need room to act and adapt.

under conditions of complexity, not only are checklists a help, they are required for success.

“David Lee Roth had a checklist!” I yelled at the radio.

On the other hand, the idea that such rates are “acceptable” was hard to swallow. Each percentage point, after all, represented millions left disabled or dead.

soap was more than soap. It was a behavior-change delivery vehicle.

Second, and just as important, the project managed to make soap use more systematic.

“Before preparing food or feeding a child is not a time when people think about washing,” Luby explained.

“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.

I was fascinated to realize that it was as much a checklist study as a soap study.

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.

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.

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.

I had assumed that achieving this kind of teamwork was mostly a matter of luck. I’d certainly experienced it at times—difficult operations in which everyone was nonetheless firing on all cylinders, acting as one.

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

The family gave me the credit, and I wish I could have taken it. But the operation had been symphonic, a thing of orchestral beauty.

Piles of checklist handbooks from US Airways, Delta, United, and other airlines lay stacked against a wall.

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 learn from the beginning of flight school that their memory and judgment are unreliable and that lives depend on their recognizing that fact.

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. Boorman didn’t think one had to be religious on this point.