The Checklist Manifesto: How to Get Things Right

The Checklist Manifesto: How to Get Things Right

by Atul Gawande

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A New York Times Bestseller

In latest bestseller, Atul Gawande shows what the simple idea of the checklist reveals about the complexity of our lives and how we can deal with it.

The modern world has given us stupendous know-how. Yet avoidable failures continue to plague us in health care, government, the law, the financial industry—in almost every realm of organized activity. And the reason is simple: the volume and complexity of knowledge today has exceeded our ability as individuals to properly deliver it to people—consistently, correctly, safely. We train longer, specialize more, use ever-advancing technologies, and still we fail. Atul Gawande makes a compelling argument that we can do better, using the simplest of methods: the checklist. In riveting stories, he reveals what checklists can do, what they can't, and how they could bring about striking improvements in a variety of fields, from medicine and disaster recovery to professions and businesses of all kinds. And the insights are making a difference. Already, a simple surgical checklist from the World Health Organization designed by following the ideas described here has been adopted in more than twenty countries as a standard for care and has been heralded as "the biggest clinical invention in thirty years" (The Independent).

Product Details

ISBN-13: 9780312430009
Publisher: Picador
Publication date: 01/04/2011
Edition description: First Edition
Pages: 240
Sales rank: 1,266
Product dimensions: 5.50(w) x 8.20(h) x 0.90(d)

About the Author

Atul Gawande is the author of Better and Complications. He is also a MacArthur Fellow, a general surgeon at the Brigham and Women's Hospital in Boston, a staff writer for The New Yorker, and an assistant professor at Harvard Medical School and the Harvard School of Public Health. He lives with his wife and three children in Newton, Massachusetts.


Newton, Massachusetts

Date of Birth:

November 5, 1965

Place of Birth:

Brooklyn, New York


B.A.S., Stanford University, 1987; M.A., Oxford University, 1989; M.D., Harvard Medical School, 1995

Read an Excerpt

The Checklist Manifesto

How to Get Things Right
By Gawande, Atul

Metropolitan Books

Copyright © 2009 Gawande, Atul
All right reserved.

ISBN: 9780805091748


Some time ago I read a case report in the Annals of Thoracic Surgery. It was, in the dry prose of a medical journal article, the story of a nightmare. In a small Austrian town in the Alps, a mother and father had been out on a walk in the woods with their three- year-old daughter. The parents lost sight of the girl for a moment and that was all it took. She fell into an icy fishpond. The parents frantically jumped in after her. But she was lost beneath the surface for thirty minutes before they finally found her on the pond bottom. They pulled her to the surface and got her to the shore. Following instructions from an emergency response team reached on their cell phone, they began cardiopulmonary resuscitation.

Rescue personnel arrived eight minutes later and took the first recordings of the girl’s condition. She was unresponsive. She had no blood pressure or pulse or sign of breathing. Her body temperature was just 66 degrees. Her pupils were dilated and unreactive to light, indicating cessation of brain function. She was gone.

But the emergency technicians continued CPR anyway. A helicopter took her to the nearest hospital, where she was wheeled directly into an operating room, a member of the emergency crewstraddling her on the gurney, pumping her chest. A surgical team got her onto a heart- lung bypass machine as rapidly as it could. The surgeon had to cut down through the skin of the child’s right groin and sew one of the desk- size machine’s silicone rubber tubes into her femoral artery to take the blood out of her, then another into her femoral vein to send the blood back. A perfusionist turned the pump on, and as he adjusted the oxygen and temperature and flow through the system, the clear tubing turned maroon with her blood. Only then did they stop the girl’s chest compressions.

Between the transport time and the time it took to plug the machine into her, she had been lifeless for an hour and a half. By the two- hour mark, however, her body temperature had risen almost ten degrees, and her heart began to beat. It was her first organ to come back.

After six hours, the girl’s core reached 98.6 degrees, normal body temperature. The team tried to shift her from the bypass machine to a mechanical ventilator, but the pond water and debris had damaged her lungs too severely for the oxygen pumped in through the breathing tube to reach her blood. So they switched her instead to an artificial- lung system known as ECMO— extracorporeal membrane oxygenation. To do this, the surgeons had to open her chest down the middle with a power saw and sew the lines to and from the portable ECMO unit directly into her aorta and her beating heart.

The ECMO machine now took over. The surgeons removed the heart- lung bypass machine tubing. They repaired the vessels and closed her groin incision. The surgical team moved the girl into intensive care, with her chest still open and covered with sterile plastic foil. Through the day and night, the intensive care unit team worked on suctioning the water and debris from her lungs with a fiberoptic bronchoscope. By the next day, her lungs had recovered sufficiently for the team to switch her from ECMO to a mechanical ventilator, which required taking her back to the operating room to unplug the tubing, repair the holes, and close her chest.

Over the next two days, all the girl’s organs recovered— her liver, her kidneys, her intestines, everything except her brain. A CT scan showed global brain swelling, which is a sign of diffuse damage, but no actual dead zones. So the team escalated the care one step further. It drilled a hole into the girl’s skull, threaded a probe into the brain to monitor the pressure, and kept that pressure tightly controlled through constant adjustments in her fluids and medications. For more than a week, she lay comatose. Then, slowly, she came back to life.

First, her pupils started to react to light. Next, she began to breathe on her own. And, one day, she simply awoke. Two weeks after her accident, she went home. Her right leg and left arm were partially paralyzed. Her speech was thick and slurry. But she underwent extensive outpatient therapy. By age five, she had recovered her faculties completely. Physical and neurological examinations were normal. She was like any little girl again.

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. Rescuing a drowning victim is nothing like it looks on television shows, where a few chest compressions and some mouth- to- mouth resuscitation always seem to bring someone with waterlogged lungs and a stilled heart coughing and sputtering back to life. To save this one child, scores of people had to carry out thousands of steps correctly: placing the heart- pump tubing into her without letting in air bubbles; maintaining the sterility of her lines, her open chest, the exposed fluid in her brain; keeping a temperamental battery of machines up and running. The degree of difficulty in any one of these steps is substantial. Then you must add the difficulties of orchestrating them in the right sequence, with nothing dropped, leaving some room for improvisation, but not too much.

For every drowned and pulseless child rescued, there are scores more who don’t make it— and not just because their bodies are too far gone. Machines break down; a team can’t get moving fast enough; someone fails to wash his hands and an infection takes hold. Such cases don’t get written up in the Annals of Thoracic Surgery, but they are the norm, though people may not realize it.

I think we have been fooled about what we can expect from medicine—fooled, one could say, by penicillin. Alexander Fleming’s 1928 discovery held out a beguiling vision of health care and how it would treat illness or injury in the future: a simple pill or injection would be capable of curing not just one condition but perhaps many. Penicillin, after all, seemed to be effective against an astonishing variety of previously untreatable infectious diseases. So why not a similar cure- all for the different kinds of cancer? And why not something equally simple to melt away skin burns or to reverse cardiovascular disease and strokes?

Medicine didn’t turn out this way, though. After a century of incredible discovery, most diseases have proved to be far more particular and difficult to treat. This is true even for the infections doctors once treated with penicillin: not all bacterial strains were susceptible and those that were soon developed resistance. Infections today require highly individualized treatment, sometimes with multiple therapies, based on a given strain’s pattern of anti biotic susceptibility, the condition of the patient, and which organ systems are affected. The model of medicine in the modern age seems less and less like penicillin and more and more like what was required for the girl who nearly drowned. Medicine has become the art of managing extreme complexity— and a test of whether such complexity can, in fact, be humanly mastered.

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. And, for nearly all of them, science has given us things we can do to help. If we cannot cure the disease, then we can usually reduce the harm and misery it causes. But for each condition


Excerpted from The Checklist Manifesto by Gawande, Atul Copyright © 2009 by Gawande, Atul. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents

Introduction 1

1 The Problem of Extreme Complexity 15

2 The Checklist 32

3 The End of the Master Builder 48

4 The Idea 72

5 The First Try 86

6 The Checklist Factory 114

7 The Test 136

8 The Hero in the Age of Checklists 158

9 The Save 187

Appendix: Example Checklists 195

Notes on Sources 201

Acknowledgments 211

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The Checklist Manifesto: How to Get Things Right 4 out of 5 based on 0 ratings. 184 reviews.
Medic More than 1 year ago
This is a "easy read" book (good writing, not very technical) that I found enjoyable and interesting. As a "manifesto," it lays out the arguments for using checklists. The author does provide some interesting history about the development of checklists (esp. aircraft flight checklists). So: checklists can be a benefit. However, the author doesn't really provide the next step. There is a science to the development and implementation of checklists. It would have been nice to have a clearer sense of how to proceed (dare I say a checklist?) and a list of resources (the chapters do have good endnotes but that's not the same).
Mike_Cummings More than 1 year ago
Like his colleague at the New Yorker, Malcolm Gladwell, Gawande has the ability to write about material that could easily be boring (in the hands of a less gifted author) in a way that is clear, engaging, and thought-provoking, without ever being condescending. This serves him well in this book, whose general topic is that most professions (his is medicine) have been overwhelmed by complexity. We have trouble getting things right, because the volume of knowledge we've created has overwhelmed our ability as individuals to follow through. Emotional Intelligence 2.0 is another book that has been really helpful in my work of late. It has a wonderful process for increasing your EQ, and improving communication between coworkers.
mundo More than 1 year ago
Anyone owning a business or all professional managers will benefit from reading Atul's book, as it may cause you, and your people, to think about how to improve the management of your business. His ideas are applicable to any industry or profession.
Anonymous More than 1 year ago
My EP recommended this book during a discussiin we had about my two recent hospitalizations. Knowing that he read it, and was, hopefully, using checklists in his surgical procedures has motivated me to devise my own checklist of questions for my doctors to use for future procedures and assessing potential physicians and surgeons. Number one will be "do you use surgical checklists?" If not, I will probably find another doctor. It's that big of a deal.
Anonymous More than 1 year ago
A self-help book, quite literally. Author shows how to make a job easier(in most cases), and more mistake-free by breaking it down into smaller pieces and checklisting those pieces. Perform those steps one by one on the list.
Anonymous More than 1 year ago
This book is a must for physicians of all levels from medical students to those in practice and even those ready to retire. I sent it to my uncle an engineer who was very fascinated. It is organized.The examples are stories in and of themselves. I Will reread this book my times and give it as gifts to all my friends and colleagues in the medical profession
Shanavi More than 1 year ago
Interesting, very well written, compelling fast read. Highly recommended to anyone in health care and anyone using health care. Should be required reading. Checklist Manifesto is one of the most import books written for health care in recent years. Its value may seem subtle in that it defends and shows the process for implementing a simple surgery checklist, but saving lives and catching medical errors with a checklist makes it profound.
Anonymous More than 1 year ago
Yes, this book is well written, but enough already. Gawande isn't doing most of this stuff himself - he is telling stories of others and sometimes he comes off as quite pompous. Many other fields in medicine have been using checklists to promote patient safety since the 1970s. Somehow Gawande passes this idea off as his own and it isn't.
Katherine Hewey More than 1 year ago
This book was buetifully written and now I can stop thinking about checklist. The author brings something as simple as a checklist to life with amazing examples of intense situations, showing how displine can calm some of the most dire situations and prevent error in one way processes. I'm not just an engineering nerd this book was sick
Anonymous More than 1 year ago
Dr. Gawande has written three excellent books. This most recent one can save many, many lives and reduce complications and errors with medical procedures. Its implications extend to other fields as well. It is a wonderful book, clear and compelling...except perhaps for the most blockheaded.
Anonymous More than 1 year ago
Some people may not be enamored with the stories and examples but the author's message is on point. We need to continually utilize checklists and whatever means are available to reduce risk in an increasingly complex world. It's in everyone's best interest to calculate risk, reduce it when possible and execute with precision. A surgeon is as good a person to tell that story as anyone.
LeighHorte on LibraryThing More than 1 year ago
Lots of detail on why checklists are useful, how to create checklists, common pitfalls, and checklist types: READ-DO and DO_CONFIRM (p123). The activation phenomenon (p108) is interesting: giving people a chance to say something at the start to activate their sense of participation, responsibility, and willingness to speak up. Pause points (p111) are a great process addition and project management tool. Root cause analysis and information overload are key concepts (p132-133) in checklist development and overall performance. There's even a bit on cognitive theory (pp163-164) to support checklist use and psychology to explain some of the usage barriers (pp161,173,183). Plus I learned there are over 13,000 ways the body can fail. Great anecdotal writing. Lacks (and needs) an index.
mattparfitt on LibraryThing More than 1 year ago
This is an engaging and inspiring book. In essence, Gawande argues that the medical profession, and certain other professions, adopt the use of checklists, as is the norm in aviation and construction. But Gawande, who writes regularly for The New Yorker, is a great story-teller, and it's hard to put this book down.The term "checklist" is just slightly misleading - or oversimplifying. The checklist is merely the instrument that ensures that critical procedures are identified and are properly followed. So this book is as much about procedures as it is about checklists, and in that way it is powerful in a great many contexts.I'm a big fan of David Allen's Getting Things Done (or "GTD") approach to task management. Gawande's ideas do not cover quite the same ground, but it's a similar kind of strategy: why try to keep a ton of things in your head when the right system allows you simply to focus on the task at hand, knowing that everything else is taken care of? Gawande declares that the age of the "Master Builder" -- the solitary genius, the inspired artiste -- is over, and that the complexity of almost any task today requires a different approach -- usually a team of experts working together. He makes a strong case for checklists -- and the whole systematic approach to managing complexity that they represent -- as the tool that's needed in today's world.
jorgearanda on LibraryThing More than 1 year ago
An accessible (but somewhat fluffy) advocacy for simple, standardized practices.
dougcornelius on LibraryThing More than 1 year ago
As a former transactional attorney, I was trained to use checklists. The transactions were too complicated to keep track of everything in my head. I also needed to communicate with the rest of the transaction team. In The Checklist Manifesto, Atul Gawande approaches checklists from the perspective of a surgeon.I had put off reading this book because I¿m already a fan of checklists. I didn¿t need to be sold on their effectiveness. But I was still floored by the effectiveness Gawande reported in his studies.In using a checklist for placing a central line, the ten-day infection rate was reduced from 11% to zero. He cites many other examples and studies that show that checklists can improve the performance of highly-trained workers.¿In a complex environment, experts are up against two main difficulties. The first is the fallibility of human memory and attention, especially when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events¿. A further difficulty, just as insidious, is that people can lull themselves into skipping steps even when they remember them. In complex processes, after all, certain steps don¿t always matter.¿I was particularly happy to see Gawande cite the correct story about Van Halen¿s use of M&M¿s as a compliance checklist tool. (See my prior post: Compliance Van Halen and Brown M&M¿s.)If you haven¿t already read The Checklist Manifesto you should add it to your reading list.
stephmo on LibraryThing More than 1 year ago
A really quick read, Atul Gawande manages to weave a compelling narrative around his call for widespread implementation of checklist development and usage in the medical field after experiencing astonishing success through a WHO project seeking to lower medical incidents during and following surgery. Before one immediately thinks, "not only do I abhor checklists, but I'm not even in the medical field!" you really need to hear what Gawande has to say. Because the checklists he cribs don't come from the medical field. They're culled heavily from pilot checklists, but also are liberally peppered with bits and pieces of checklists (theory and practice) from areas as diverse as construction, restaurants, rock and roll and venture capital. This isn't about the need to cookie-cutter every single process one does, but rather to ensure that the mundane basics are not skipped over in a mad rush to get to the sexier, more important stuff. If you're involved in an organization of any kind that deals with some sort of process, you will find some insight in this slim volume.
YogiABB on LibraryThing More than 1 year ago
Atul Gawande is a surgeon who has written this book about checklists but it is not a book on how to make checklists for shopping lists or planning weddings nor is it a book about productivity. This is a book on using checklists as a tool to deal with modern technology's extreme complexity to avoid disasters and death.This came to the forefront with the development of the B-17 Bomber in the 1930's. The plane was very complex and difficult to fly under the best of conditions. When things went wrong pilots made very obvious mistakes that led to crashes. In response Boeing developed very simple checklists that when used cut down on the number of crashes considerably.He also talks about modern buildings. The incidence of failure of high rise buildings has been ridiculously low. Much of that is because of the use of checklists during the design and construction of the buildings. Everybody knows that know one person can think of everything in such a project so they depend on codes and lists in order to ensure the safety of the buildings.Dr. Gawande really blasts his fellow doctors for being so resistant to standards of care and checklists for even the simplest of procedures. Standards and checklists that have been proven to work if followed. The problem is the ego of many doctors to hand power briefly over to somebody else for the briefest of times in order to make sure that the procedure is to be done.The problem, as almost everyone who has ever dealt with the medical profession knows, is that doctors are treated like royalty and everyone else, nurses, technicians, and other highly educated, trained, and experienced professionals and especially the patients, are there at the doctor's bidding. I asked a nurse last year when a family member was hospitalized what her number one problem was in her job. She said that, besides the workload, trying to explain to patients and their family members that she couldn't tell them anything about test results or treatment plans or anything else. They had to wait for the doctor to tell them that and then telling the patients that she had no idea when the doctor was coming by, that in fact he or she was going to come by when they pleased and not a minute before. Further, they could page or call him or her till the cows come home and it would not do any good. She said that the whole floor of the hospital was full of people wondering and waiting when the doctor was going to come.She said it as pretty frustrating. I think that there has to be a better way.What do you think?Oh yeah, I rate this book 2.5 stars out of 4. I mean its a good book but it is still only about checklists. At least it was short. But really, isn't 200 pages like a graduate degree in checklists?
sandyreader on LibraryThing More than 1 year ago
What do airline pilots, good operating hospitals, builders of skyscrapers, and rocker David Lee Roth have in common? It's a checklist.When surgeon Atul Gawande presented the idea of this checklist tohospitals his ideas, at first, were brushed aside as more work, butas time went on and with astonishing results, he was vindicated andmore and more hospitals have added this to their surgery theaters.In this excellent book, he ties all this together in an interestingway. I'm not a fan of books on hospitals, but there is so much moreof interest that most everyone will learn and be entertained byThe Checklist Manifesto.
horacewimsey on LibraryThing More than 1 year ago
Good initiative, execution a bit overlong. The basic idea is this: Creating good checklists and following them religiously is shown to catch mistakes before it's too late. The book made this point but used too many anecdotes along the way.
alphaorder on LibraryThing More than 1 year ago
Although Gawande uses his experiences as a surgeon to highlight the importance of checklists, his findings can be translated into any type of work. One of my favorite quotes:"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."He suggests that checklists encourage both teamwork and discipline.Another interesting takeaway: "We don't look for the patterns of our recurrent mistakes or devise and refine potential solutions for them." He suggests that if we do so and incorporate our solutions into our checklists, we will reduce errors and increase efficiency, no matter what our profession.Gawande's final example of how the checklist possibly changed an outcome is the safe landing of the flight in the Hudson in January 2009. The details are fascinating.I enjoyed this short, readable book. By developing my own checklists, I am sure that it will have impact.
SamanthaMarie on LibraryThing More than 1 year ago
Yet another fascinating book by Atul Gawande. This one is more than just a series of stories about medicine. Gawande explores the idea of using checklists in medicine and whether that would cut down on the kinds of mistakes that kill and injure thousands of patients every year. He suggests that it is not ignorance of doctors or nurses, but that medicine has become so complicated that it is impossible for anyone to remember everything, especially the mundane details that end up being so important. He goes into detail on the constructionn/architecture field and how they have used checklists. He also looks at aviation and used their checklists to guide his formulation of surgery checklists since their time constraints are similar. There is a very interesting chapter on the landing on the Hudson at the end of the book. I would recommend this book to just about anyone who likes to read and has ever used a medical facility.I grabbed this book for free from the publishers booth at ALA Midwinter mostly because I've read his other books and loved them.
ldmarquet on LibraryThing More than 1 year ago
The Checklist ManifestoIn 1936 when Boeing introduced a new bomber, labeled the Model 299 it crashed on its competitive test flight by an experienced test-pilot. See, this new plane with 4 engines was significantly more complicated than any that preceded it and relying on pilots¿ memory for operations would no longer work. The response ¿ a checklist. The result was successful operation by thousands of pilots and the contribution of the B-17 to winning the war. This is one of the many compelling stories that Atul Gawande tells to get his message across that checklists are the answer to complexity and that modern medicine is incredibly complex. The implication is that modern medical teams are essentially at the point where aviation was in 1936.Fundamentally, Gawande is right as anyone who has operated a nuclear powered submarine knows. There is a parallel between what Gawande is advocating and the broader leadership theme that procedures trump personality that limits the current models of leadership. The case is overdone however. You¿d think no one ever used a checklist in a hospital until Gawande educated them. Further, the B-17 didn¿t crash because of the complexity of the engines ¿ it crashed because the flight surfaces were never unlocked and tested ¿ something that could happen on an airplane with only one engine.
tgraettinger on LibraryThing More than 1 year ago
This book was a quick-and-easy read. It focused on the use and potential of simple checklists in a variety of fields. These fields ranged from medicine (primarily surgery), aviation, finance, and construction. The stories were good and inspiring, but the book comes up short on the "how-to". Despite the simplicity of the end product, it was clear that developing a *good* checklist requires much more than writing down a set of steps. Maybe a checklist for creating a good checklist is in order.
kaelirenee on LibraryThing More than 1 year ago
I¿m the kind of person who used to always write a shopping list, then forget it on my kitchen table, and come home without milk. I started devoting a section of my planner to post it notes with reminders and I don¿t go into a store without my shopping list. In Checklist Manifesto, Atul Gawande presents the benefits to professionals for using short lists to keep them from metaphorically forgetting the milk. This book is part memoir, part research review. Gawande is a prominent surgeon who worked with the World Health Organization to come up with low-cost methods to improve surgery outcomes. Through research in other fields, especially aviation, they composed a short, two minute checklist.He focuses on the need for checklists, the uses for checklists, the composition of lists, and the psychology behind the people using these lists. Of all the issues confronted, the psychology of using checklists is the most problematic. Professionals are trained and smart and don¿t want to be reminded of every little detail. They are above the menial tasks listed in a checklist. But the important message I took from this book was that, by freeing up the mind from all the menial details, you can focus on the unexpected. His examples are primarily from his own field, surgery. For instance, by telling people in the operating room how much blood he expects to be lost and what problems he can foresee, nurses were able to have packed blood on hand, just in case. There are also numerous examples from the field that pioneered these checklists, aviation. The key example from this field is the ¿Miracle on the Hudson¿ from January 2009, in which a flight crew managed to make an emergency landing in the Hudson River after a double bird strike took out the engines.Gawande admits his own failures and shortcomings, a trait that I admire from a renowned surgeon. He presents his mistakes with a candor that acknowledges room for improvement that all humans have. I know that if I were going into surgery, I would want my surgical team to use his checklist (and apparently, so did 93% of the surgeons in this study). I can also imagine that all of these saved lives and avoided postoperative problems save quite a bit of money, so I¿m shocked more insurance companies haven¿t incentivized their use.I would like to see this study expanded to more professions, too. But first, we must admit where we¿ve made mistakes and which are the easiest to avoid. Like forgetting the milk.
dazzyj on LibraryThing More than 1 year ago
A heartfelt and thoughtful call for simple systematics action to prevent potentially catastrophic failure.