The Checklist Manifesto: How To Get Things Right

by Atul Gawande

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

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

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

is the complexity that science has dropped upon us and the enormous strains we are encountering in making good on its promise.

Know-how and sophistication have increased remarkably across almost all our realms of endeavor, and as a result so has our struggle to deliver on them.

And defeat under conditions of complexity occurs far more often despite great effort rather than from a lack of it.

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.

It is a checklist.

What makes this recovery astounding isn’t just the idea that someone could be brought back after two hours in a state that would once have been considered death. It’s also the idea that a group of people in a random hospital could manage to pull off something so enormously complicated.

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.

What they decided not to do was almost as interesting as what they actually did.

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

What, for instance, are the vital signs that every hospital records if not a kind of checklist?

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.

In most hospitals, nurses have since added a fifth vital sign: pain, as rated by patients on a scale of one to ten.

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

They provide a kind of cognitive net.

So a key step is to identify which kinds of situations checklists can help with and which ones they can’t.

Simple problems, they note, are ones like baking a cake from a mix.

Complicated problems are ones like sending a rocket to the moon.

Complex problems are ones like raising a child.

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

Forget the paperwork. Take care of the patient.

And I wondered: How did he and all his co-workers know that they were building this thing right? How could they be sure that it wouldn’t fall down?

And that was how I discovered the concept of bracing.

First, how could they be sure that they had the right knowledge in hand? Second, how could they be sure that they were applying this knowledge correctly?

‘Here, we want you to memorize these formulas,’

‘Why do I have to memorize them if I know where the book is?’

There, on the walls around a big white oval table, hung sheets of butcher-block-size printouts of what were, to my surprise, checklists.

There was special color coding, with red items highlighting critical steps that had to be done before other steps could proceed.

They didn’t believe in the wisdom of the single individual, of even an experienced engineer. 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.

Clash Detective

Project Center,

the perfection of tracking and communication.

“tuned mass damper.”

“The biggest cause of serious error in this business is a failure of communication,”

The checklists work.

The philosophy is that you push the power of decision making out to the periphery and away from the center. You give people the room to adapt, based on their experience and expertise. All you ask is that they talk to one another and take responsibility. That is what works.

was a lack of understanding that, in the face of an extraordinarily complex problem, power needed to be pushed out of the center as far as possible.

“This company will respond to the level of this disaster,”

“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.”

That routine requires balancing a number of virtues: freedom and discipline, craft and protocol, specialized ability and group collaboration.

They supply a set of checks to ensure the stupid but critical stuff is not overlooked, and they supply another set of checks to ensure people talk and coordinate and accept responsibility while nonetheless being left the power to manage the nuances and unpredictabilities the best they know how.

How could we possibly attempt to address so many different issues in so many different places?

Studies in the United States alone had found that at least half of surgical complications were preventable.

The most straightforward thing for the group to do would have been to formulate and publish under the WHO name a set of official standards for safe surgical care.

And the interventions proved to have widely transmissible benefits—what business types would term a large ROI (return on investment) or what Archimedes would have called, merely, leverage.

Families in the test neighborhoods received an average of 3.3 bars of soap per week for one year. During this period, the incidence of diarrhea among children in these neighborhoods fell 52 percent compared to that in the control group, no matter which soap was used. The incidence of pneumonia fell 48 percent. And the incidence of impetigo, a bacterial skin infection, fell 35 percent. These were stunning results. And they were achieved despite the illiteracy, the poverty, the crowding, and even the fact that, however much soap they used, people were still drinking and washing with contaminated water.

It was a behavior-change delivery vehicle. The researchers hadn’t just handed out Safeguard, after all. They also gave out instructions—on leaflets and in person—explaining the six situations in which people should use it.

The surgical director measured the effect on care. 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.