The Checklist Manifesto: How to Get Things Right

Atul Gawande

Apr 2010 · Sold by Metropolitan Books

About this ebook

The New York Times bestselling author of Being Mortal and Complications reveals the surprising power of the ordinary checklist

We live in a world of great and increasing complexity, where even the most expert professionals struggle to master the tasks they face. Longer training, ever more advanced technologies—neither seems to prevent grievous errors. But in a hopeful turn, acclaimed surgeon and writer Atul Gawande finds a remedy in the humblest and simplest of techniques: the checklist. First introduced decades ago by the U.S. Air Force, checklists have enabled pilots to fly aircraft of mind-boggling sophistication. Now innovative checklists are being adopted in hospitals around the world, helping doctors and nurses respond to everything from flu epidemics to avalanches. Even in the immensely complex world of surgery, a simple ninety-second variant has cut the rate of fatalities by more than a third.

In riveting stories, Gawande takes us from Austria, where an emergency checklist saved a drowning victim who had spent half an hour underwater, to Michigan, where a cleanliness checklist in intensive care units virtually eliminated a type of deadly hospital infection. He explains how checklists actually work to prompt striking and immediate improvements. And he follows the checklist revolution into fields well beyond medicine, from disaster response to investment banking, skyscraper construction, and businesses of all kinds.

An intellectual adventure in which lives are lost and saved and one simple idea makes a tremendous difference, The Checklist Manifesto is essential reading for anyone working to get things right.

Ratings and reviews

In The Checklist Manifesto, Dr. Atul Gawande examines how the use of checklists can significantly improve workflows and outcomes in the work environment. He focuses primarily on the aviation and construction industries, and analyzes where and how checklists are used. He speaks as well about his experience in a WHO-sponsored initiative bringing checklists to surgical operating theatres around the world. Dr. Gawande examines in some detail the genesis of checklists in the aviation industry, a major result of which is the incredible safety record that the industry enjoys, despite the obvious complexity involved in any flight. He notes that checklists are generally of two kinds, PAUSE AND CHECK and READ AND DO. An example of the first would be the checklists that an airplane pilot goes through before starting the engines. An example of the second would be the type that one consults when one encounters an unexpected event. In a legal context, READ AND DO checklists would be used at the outset or at some point during a matter (for example, when starting to draft an agreement or pleadings), while a PAUSE AND CHECK list would be used before some important milestone (for example, immediately before the beginning of a trial or a closing). Near the end of the book, the author analyzes the “miracle on the Hudson” landing of a jet liner on the Hudson River a year ago. When both engines failed at the same time, the pilot went first to the checklist relating to catastrophic engine failure. Although painted in the press as a hero who single-handedly engineered the safe landing, the pilot continued to say that this “miracle” was the result not of individual effort but rather of teamwork. One key aspect of the success of checklists is its length and simplicity. A good checklist, the author says, has between five and nine points and is sufficiently concise that it fits on one page. (The binder of aviation checklists is about two inches thick.) One could envisage, in our context, a general checklist relating to firm opinions; one each for addressing issues where our client is a corporation, a limited partnership, or a trust; a checklist where we are acting as agent; etc. Equally important is the need to continually test the checklists in “real life” to ensure that they work effectively. Dr. Gawande notes that his WHO committee prepared a first draft of a surgical checklist, which he thought was very effective. But the first time he used it, the others in the OR found it raised almost as many questions as there were points on the list. It had to go through many iterations to get to a state that everyone judged acceptable and – most importantly – is continually updated. He notes that the aviation industry has been diligent in studying the causes of unexpected incidents (for example, after crashes or “near misses”), determining the cause(s), and then taking all appropriate steps (primarily, updating the relevant checklists) to address the issue if it were to arise again. (One may be tempted, when reading of the aviation’s industry’s efforts, to reflect on how often – or, more to the point, how infrequently – lawyers engage any sort of after action review of the positive lessons learned, let alone any analysis of mistakes made and how we could learn from them.) The author spends some time looking at checklists used in building a 33-storey addition to his hospital and specifically how the builders, who are managing 16 different trades, each with their own specialities, have one set of checklists for what “should” happen, but also another set that specifically provide for unexpected events. (Similarly, airlines have checklists for things like catastrophic engine failure.) The key point here is that building industry has built into its preparedness an expectation that things will not go exactly as planned. In my experience, however, most legal matters are conducted as if every expected them to run without problem, and when the unexpected occurs, it is truly unexpected. Both the

"This book is about how checklists can help us cope with the ever increasing complex world that we live in. It traces the origins of checklists as well as industries where it has been used successfully as he weaves the story of his efforts to create one for surgery. This is a very exciting book especially in the end where he describes how checklists engender team work that helped save lives on US Airways Flight 1549. He surprised me with the final chapter; I'll let you read to find out what it is about."

--------------- The Checklist Manifesto How lists of the ‘dumb stuff’ can save us from disaster How to Get Things Right By Atul Gawande Metropolitan Books, $24/ Profile Books, £12.99 in Financial Times A recent study in the journal Science showed that rats stop thinking and resort to habit when they are under extreme stress. Humans might well do the same. Nonetheless we appear to believe that in our professional lives, such stress will produce an adrenalin-fuelled surge of clear and brilliant thought. It doesn’t. And in the ensuing muddle, mistakes – sometimes fatal – are made. Atul Gawande, a surgeon, Harvard Medical School professor and staff writer for The New Yorker, has written a welcome book to convince us of the distinction between unavoidable failures and those we can avert. The Checklist Manifesto is a slim volume but it is packed with vivid writing heart-stopping anecdotes and statistical surprises. This is Gawande’s third book, but his first aimed at a wider business audience than fellow physicians. It draws on a variety of sectors, including finance, architecture and aviation. Teamwork is the book’s focus and so should appeal to business managers everywhere who are grappling with this thorny subject. As he says, “Man is fallible, but maybe men are less so.” Gawande argues that simple checklists are the key to preventing small mistakes from becoming a full-scale disaster. The jobs of financial managers, doctors, software engineers and others “are too complex to carry out reliably from memory alone,” he warns. Checklists are to be deployed as an agent of humility, to lift the illusion of professional omniscience and to inspire teamwork in an era of specialisation. Gawande’s checklists are not scribbled notes but are announced and discussed by everyone in a room. This is no easy task – it can wound the ego, he admits. Team members can be embarrassed to be seen as pen-wielding automatons, checking up on their peers or questioning authority. Gawande takes pains, as a result, to make checklists unthreatening. They get “the dumb stuff out of the way”, he says. This solution is so obvious that it seems hokey. But the book scours various industries for examples of professionals who have failed to use a checklist as simple reminders to prevent panicked thoughts from overtaking rational actions. So, Boeing provides a checklist for pilots in crisis, including the simple directive: “Fly the plane.” In describing what can happen in the absence of checklists, Gawande wields a breezy prose and intense curiosity about the subject. He grabs the reader with bracing anecdotes of stomach-churning disaster: simple errors that cause surgeries to fail and aircraft to crash. Gawande’s treatment of finance is too short, however. He mentions several investors who used checklists to earn outsized returns, notably Mohnish Pabrai, a California investor, who saw returns of almost 160 per cent on investments in 2008, using a list of 70 or more items, including reminders to examine footnotes on financial statements. However, the money men overall get less attention compared to other professions. His most searing analysis is from his own field, medicine, where checklist use, he writes, has reduced costs and fatalities. He cites the example of one hospital that saved $2m (€1.38m, £1.25m), prevented 43 infections and eight deaths after implementing checklists. If there is a criticism of this book, it is that it is heavy on anecdote but light on insight. Some of the author’s best observations are made in passing – for example, his finding that checklists can get high-powered personalities to function as a close-knit and coherent team. Considering how many managers face this challenge, Gawande would have done well to examine the idea in depth. Nonetheless, he makes a compelling argument for attention to detail in this age of automation, when so much appears

About the author

Atul Gawande is the author of several bestselling books: Complications, a finalist for the National Book Award; Better; The Checklist Manifesto; and Being Mortal. He is also a surgeon at Brigham and Women's Hospital in Boston, a staff writer for The New Yorker, and a professor at Harvard Medical School and the Harvard School of Public Health. He has won the Lewis Thomas Prize for Writing about Science, a MacArthur Fellowship, and two National Magazine Awards. In his work in public health, he is Founder and Chair of Ariadne Labs, a joint center for health systems innovation, and Lifebox, a nonprofit organization making surgery safer globally. He is also chair of Haven, where he was CEO from 2018–2020. He and his wife have three children and live in Newton, Massachusetts.