The Checklist Manifesto: How to Get Things Right

by Atul Gawande

(He went so far as to recommend using a sans serif type like Helvetica.)

But Boorman was adamant about one further point: 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.

Who, for example, was supposed to bring things to a halt and kick off the checklist? We’d been vague about that, but it proved no small decision.

An inherent tension exists between brevity and effectiveness.

By comparison, some 300,000 operations result in a surgical site infection, and more than eight thousand deaths are associated with these infections. We have done far better at preventing fires than infections. Since the checks required to entirely eliminate fires would make the list substantially longer, these were dropped as well.

Improving teamwork was so fundamental to making a difference, however, that we were willing to leave these measures in and give them a try.

After anesthesia, but before incision, come seven more checks. The team members make sure they’ve been introduced by name and role.

Why describe the checklist? Just show us!!

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

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.

“You have to change your glove,” the nurse told him in Arabic. (Someone translated for me.) “It’s fine,” the surgeon said. “No, it’s not,” the nurse said. “Don’t be stupid.” Then she made him change his glove.

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.

Suppose this was just a Hawthorne effect, that is to say, a byproduct of being observed in a study rather than proof of the checklist’s power.

We surmised that improved communication was the key.

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.

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

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

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

In large part, he believes, the mistakes happened because he wasn’t able to damp down the cocaine brain.

All this is to say he knows a thing or two about being dispassionate and avoiding the lure of instant gratification.

when analyzing a company, stop and confirm that you’ve asked yourself whether the revenues might be overstated or understated due to boom or bust conditions.

By that point, the checklist says, they should confirm that they have gone over the prospect’s key financial statements for the previous ten years, including checking for specific items in each statement and possible patterns across the statements.

If someone is doing well, people pounce like starved hyenas to find out how.