The Checklist Manifesto: How To Get Things Right

by Atul Gawande

If the knowledge of the best thing to do in a given situation does not exist, we are happy to have people simply make their best effort. But if the knowledge exists and is not applied correctly, it is difficult not to be infuriated.

Here, then, is our situation at the start of the twenty-first century: We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And, with it, they have indeed accomplished extraordinary things. Nonetheless, that know-how is often unmanageable. 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.

Moreover, research has consistently showed that at least half our deaths and major complications are avoidable. The knowledge exists. But however supremely specialized and trained we may have become, steps are still missed. Mistakes are still made.

What do you do when expertise is not enough? What do you do when even the super-specialists fail? We’ve begun to see an answer, but it has come from an unexpected source—one that has nothing to do with medicine at all.

The test pilots made their list simple, brief, and to the point—short enough to fit on an index card, with step-by-step checks for takeoff, flight, landing, and taxiing. It had the kind of stuff that all pilots know to do. They check that the brakes are released, that the instruments are set, that the door and windows are closed, that the elevator controls are unlocked—dumb stuff. You wouldn’t think it would make that much difference. But with the checklist in hand, the pilots went on to fly the Model 299 a total of 1.8 million miles without one accident. The army ultimately ordered almost thirteen thousand of the aircraft, which it dubbed the B-17. And, because flying the behemoth was now possible, the army gained a decisive air advantage in the Second World War, enabling its devastating bombing campaign across Nazi Germany.

Much of our work today has entered its own B-17 phase. Substantial parts of what software designers, financial managers, firefighters, police officers, lawyers, and most certainly clinicians do are now too complex for them to carry out reliably from memory alone. Multiple fields, in other words, have become too much airplane for one person to fly.

“This has never been a problem before,” people say. Until one day it is.

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. Which is precisely what happened with vital signs—though it was not doctors who deserved the credit.

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

He tried the usual surgical approach to remedy this—yelling at everyone to get their act together. But still they had no saves. So he and a couple of colleagues decided to try something new. They made a checklist.

Four generations after the first aviation checklists went into use, a lesson is emerging: checklists seem able to defend anyone, even the experienced, against failure in many more tasks than we realized. They provide a kind of cognitive net. They catch mental flaws inherent in all of us—flaws of memory and attention and thoroughness. And because they do, they raise wide, unexpected possibilities.

But they presumably have limits, as well. So a key step is to identify which kinds of situations checklists can help with and which ones they can’t.

All were amenable, as a result, to what engineers call “forcing functions”: relatively straightforward solutions that force the necessary behavior—solutions like checklists.

Man is fallible, but maybe men are less so.

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.

“It makes sense,” O’Sullivan said. “The inspectors have more troubles with the safety of a two-room addition from a do-it-yourselfer than they do with projects like ours. So that’s where they focus their efforts.” Also, I suspect, at least some authorities have recognized that when they don’t let go of authority they fail.

The trouble wasn’t a lack of sympathy among top officials. It 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. Everyone was waiting for the cavalry, but a centrally run, government-controlled solution was not going to be possible.

“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. 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.

That routine requires balancing a number of virtues: freedom and discipline, craft and protocol, specialized ability and group collaboration. And for checklists to help achieve that balance, they have to take two almost opposing forms. 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.

under conditions of complexity, not only are checklists a help, they are required for success. There must always be room for judgment, but judgment aided—and even enhanced—by procedure.

But the fourth killer—the unexpected—is an entirely different kind of failure, one that stems from the fundamentally complex risks entailed by opening up a person’s body and trying to tinker with it. Independently, each of the researchers seemed to have realized that no one checklist could anticipate all the pitfalls a team must guard against. So they had determined that the most promising thing to do was just to have people stop and talk through the case together—to be ready as a team to identify and address each patient’s unique, potentially critical dangers.

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 professionals using them could miss. Good checklists are, above all, practical.

Pilots nonetheless turn to their checklists for two reasons. First, they are trained to do so. They learn from the beginning of flight school that their memory and judgment are unreliable and that lives depend on their recognizing that fact. Second, the checklists have proved their worth—they work.

You must define a clear pause point at which the checklist is supposed to be used (unless the moment is obvious, like when a warning light goes on or an engine fails). 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 wording should be simple and exact, Boorman went on, and use the familiar language of the profession. Even the look of the checklist matters. Ideally, it should fit on one page. It should be free of clutter and unnecessary colors. It should use both uppercase and lowercase text for ease of reading. (He went so far as to recommend using a sans serif type like Helvetica.)

It is common to misconceive how checklists function in complex lines of work. They are not comprehensive how-to guides, whether for building a skyscraper or getting a plane out of trouble. They are quick and simple tools aimed to buttress the skills of expert professionals. And by remaining swift and usable and resolutely modest, they are saving thousands upon thousands of lives.

In aviation, there is a reason the “pilot not flying” starts the checklist, someone pointed out. The “pilot flying” can be distracted by flight tasks and liable to skip a checklist. Moreover, dispersing the responsibility sends the message that everyone—not just the captain—is responsible for the overall well-being of the flight and should have the power to question the process. If a surgery checklist was to make a difference, my colleagues argued, it needed to do likewise—to spread responsibility and the power to question. So we had the circulating nurse call the start.

All involve risk, uncertainty, and complexity—and therefore steps that are worth committing to a checklist and testing in routine care.

We have the means to make some of the most complex and dangerous work we do—in surgery, emergency care, ICU medicine, and beyond—more effective than we ever thought possible. But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity—the right stuff, again. Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.

It’s ludicrous, though, to suppose that checklists are going to do away with the need for courage, wits, and improvisation. The work of medicine is too intricate and individual for that: good clinicians will not be able to dispense with expert audacity. Yet we should also be ready to accept the virtues of regimentation.

And it is true well beyond medicine. The opportunity is evident in many fields—and s...

“You go into greed mode,” he said. Guy Spier called it “cocaine brain.” Neuroscientists have found that the prospect of making money stimulates the same primitive reward circuits in the brain that cocaine does.

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. I asked him whether he wasn’t fooling himself. “Maybe,” he said. But he put it in surgical terms for me. “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.”

How much of any success can be directly credited to the checklist is not clear—after all, he’s used it just two years so far. What Cook says is certain, however, was that in a period of enormous volatility the checklist gave his team at least one additional and unexpected edge over others: efficiency.

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.

In the money business, everyone looks for an edge. If someone is doing well, people pounce like starved hyenas to find out how. Almost every idea for making even slightly more money—investing in Internet companies, buying tranches of sliced-up mortgages, whatever—gets sucked up by the giant maw almost instantly. Every idea, that is, except one: checklists.

I asked Cook how much interest others have had in what he has been doing these past two years. Zero, he said—or actually that’s not quite true. People have been intensely interested in what he’s been buying and how, but the minute the word checklist comes out of his ...

“I got pushback from everyone. It took my guys months to finally see the value,” he said. To this day, his partners still don’t all go along with his approach and don’t use the checklist in their decisions when he’s not involved. “I find it amazing other investors have n...

The most interesting discovery was that, despite the disadvantages, 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, maybe the others didn’t know about the Airline Captain approach. But even knowing seems to make little difference. Smart published his findings more than a decade ago. He has since gone on to explain them in a best-selling business book on hiring called Who. But when I asked him, now that the knowledge is out, whether the proportion of major investors taking the more orderly, checklist-driven approach has increased substantially, he could only report, “No. It’s the same.”

We don’t like checklists. They can be painstaking. They’re not much fun. But I don’t think the issue here is mere laziness. There’s something deeper, more visceral going on when people walk away not only from saving lives but from making money. It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us—those we aspire to be—handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists. Maybe our idea of heroism needs updating.

The fear people have about the idea of adherence to protocol is rigidity. They imagine mindless automatons, heads down in a checklist, incapable of looking out their windshield and coping with the real world in front of them. But what you find, when a checklist is well made, is exactly the opposite. The checklist gets the dumb stuff out of the way, the routines your brain shouldn’t have to occupy itself with (Are the elevator controls set? Did the patient get her antibiotics on time? Did the managers sell all their shares? Is everyone on the same page here?), and lets it rise above to focus on the hard stuff (Where should we land?).

All learned occupations have a definition of professionalism, a code of conduct. It is where they spell out their ideals and duties. The codes are sometimes stated, sometimes just understood. But they all have at least three common elements. First is an expectation of selflessness: that we who accept responsibility for others—whether we are doctors, lawyers, teachers, public authorities, soldiers, or pilots—will place the needs and concerns of those who depend on us above our own. Second is an expectation of skill: that we will aim for excellence in our knowledge and expertise. Third is an expectation of trustworthiness: that we will be responsible in our personal behavior toward our charges.

Aviators, however, add a fourth expectation, discipline: discipline in following prudent procedure and in functioning with others. This is a concept almost entirely outside the lexicon of most professions, including my own. In medicine, we hold up “autonomy” as a professional lodestar, a principle that stands in direct opposition to discipline.

To be sure, checklists must not become ossified mandates that hinder rather than help. Even the simplest requires frequent revisitation and ongoing refinement. Airline manufacturers put a publication date on all their checklists, and there is a reason why—they are expected to change with time. In the end, a checklist is only an aid. If it doesn’t aid, it’s not right. But if it does, we must be ready to embrace the possibility.

One essential characteristic of modern life is that we all depend on systems—on assemblages of people or technologies or both—and among our most profound difficulties is making them work.

Berwick notes how wrongheaded this approach is. “Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence,” he says.

The same can be said in numerous other fields. We don’t study routine failures in teaching, in law, in government programs, in the financial industry, or elsewhere. We don’t look for the patterns of our recurrent mistakes or devise and refine potential solutions for them. But we could, and that is the ultimate point. We are all plagued by failures—by missed subtleties, overlooked knowledge, and outright errors. For the most part, we have imagined that little can be done beyond working harder and harder to catch the problems and clean up after them. We are not in the habit of thinking the way the army pilots did as they looked upon their shiny new Model 299 bomber—a machine so complex no one was sure human beings could fly it. They too could have decided just to “try harder” or to dismiss a crash as the failings of a “weak” pilot. Instead they chose to accept their fallibilities. They recognized the simplicity and power of using a checklist. And so can we. Indeed, against the complexity of the world, we must. There is no other choice. When we look closely, we recognize the same balls being dropped over and over, even by those of great ability and determination. We know the patterns. We see the costs. It’s time to try something else. Try a checklist.