The New York Times bestselling author of Better 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.
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About the Author
Atul Gawande is the author of Better and Complications, a National Book Award finalist. 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 served as a senior health policy advisor in the Clinton presidential campaign and White House from 1992 to 1993. He received his B.A.S. from Stanford University, M.A. in politics, philosophy and economics from Oxford University, M.D. from Harvard Medical School, and M.P.H. from the Harvard School of Public Health. He lives with his wife and three children in Newton, Massachusetts.
Atul Gawande is author of three bestselling books: Complications, a finalist for the National Book Award; Better, selected by Amazon.com as one of the ten best books of 2007; and The Checklist Manifesto. His latest book is Being Mortal: Medicine and What Matters in the End. 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 Executive Director of Ariadne Labs, a joint center for health systems innovation, and chairman of Lifebox, a nonprofit organization making surgery safer globally. He and his wife have three children and live in Newton, Massachusetts.
Date of Birth:November 5, 1965
Place of Birth:Brooklyn, New York
Education:B.A.S., Stanford University, 1987; M.A., Oxford University, 1989; M.D., Harvard Medical School, 1995
Read an Excerpt
1. THE PROBLEM OF EXTREME COMPLEXITY
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 crew straddling 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 the steps are different and they are almost never simple. 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.
There is a community clinic in Boston’s Kenmore Square affiliated with my hospital. The word clinic makes the place sound tiny, but it’s nothing of the sort. Founded in 1969, and now called Harvard Vanguard, it aimed to provide people with the full range of outpatient medical services they might need over the course of their lives. It has since tried to stick with that plan, but doing so hasn’t been easy. To keep up with the explosive growth in medical capabilities, the clinic has had to build more than twenty facilities and employ some six hundred doctors and a thousand other health professionals covering fifty- nine specialties, many of which did not exist when the clinic first opened. Walking the fifty steps from the fifth- floor elevator to the general surgery department, I pass offices for general internal medicine, endocrinology, genetics, hand surgery, laboratory testing, nephrology, ophthalmology, orthopedics, radiology scheduling, and urology— and that’s just one hallway.
To handle the complexity, we’ve split up the tasks among various specialties. But even divvied up, the work can become overwhelming. In the course of one day on general surgery call at the hospital, for instance, the labor floor asked me to see a twenty-five- year- old woman with mounting right lower abdominal pain, fever, and nausea, which raised concern about appendicitis, but she was pregnant, so getting a CT scan to rule out the possibility posed a risk to the fetus. A gynecological oncologist paged me to the operating room about a woman with an ovarian mass that upon removal appeared to be a metastasis from pancreatic cancer; my colleague wanted me to examine her pancreas and decide whether to biopsy it. A physician at a nearby hospital phoned me to transfer a patient in intensive care with a large cancer that had grown to obstruct her kidneys and bowel and produce bleeding that they were having trouble controlling. Our internal medicine service called me to see a sixty- one- year- old man with emphysema so severe he had been refused hip surgery because of insufficient lung reserves; now he had a severe colon infection— an acute diverticulitis— that had worsened despite three days of antibiotics, and surgery seemed his only option. Another service asked for help with a fifty- two- year- old man with diabetes, coronary artery disease, high blood pressure, chronic kidney failure, severe obesity, a stroke, and now a strangulating groin hernia. And an internist called about a young, otherwise healthy woman with a possible rectal abscess to be lanced.
Confronted with cases of such variety and intricacy— in one day, I’d had six patients with six completely different primary medical problems and a total of twenty- six different additional diagnoses— it’s tempting to believe that no one else’s job could be as complex as mine. But extreme complexity is the rule for almost everyone. I asked the people in Harvard Vanguard’s medical records department if they would query the electronic system for how many different kinds of patient problems the average doctor there sees annually. The answer that came back flabbergasted me. Over the course of a year of office practice— which, by definition, excludes the patients seen in the hospital— physicians each evaluated an average of 250 different primary diseases and conditions. Their patients had more than nine hundred other active medical problems that had to be taken into account. The doctors each prescribed some three hundred medications, ordered more than a hundred different types of laboratory tests, and performed an average of forty different kinds of office procedures— from vaccinations to setting fractures.
Even considering just the office work, the statistics still didn’t catch all the diseases and conditions. One of the most common diagnoses, it turned out, was "Other." On a hectic day, when you’re running two hours behind and the people in the waiting room are getting irate, you may not take the time to record the precise diagnostic codes in the database. But, even when you do have the time, you commonly find that the particular diseases your patients have do not actually exist in the computer system.
The software used in most American electronic records has not managed to include all the diseases that have been discovered and distinguished from one another in recent years. I once saw a patient with a ganglioneuroblastoma (a rare type of tumor of the adrenal gland) and another with a nightmarish genetic condition called Li- Fraumeni syndrome, which causes inheritors to develop cancers in organs all over their bodies. Neither disease had yet made it into the pull- down menus. All I could record was, in so many words, "Other." Scientists continue to report important new genetic findings, subtypes of cancer, and other diagnoses— not to mention treatments— almost weekly. The complexity is increasing so fast that even the computers cannot keep up.
But it’s not only the breadth and quantity of knowledge that has made medicine complicated. It is also the execution— the practical matter of what knowledge requires clinicians to do. The hospital is where you see just how formidable the task can be. A prime example is the place the girl who nearly drowned spent most of her recovery— the intensive care unit.
It’s an opaque term, intensive care. Specialists in the field prefer to call what they do critical care, but that still doesn’t exactly clarify matters. The nonmedical term life support gets us closer. The damage that the human body can survive these days is as awesome as it is horrible: crushing, burning, bombing, a burst aorta, a ruptured colon, a massive heart attack, rampaging infection. These maladies were once uniformly fatal. Now survival is commonplace, and a substantial part of the credit goes to the abilities intensive care units have developed to take artificial control of failing bodies. Typically, this requires a panoply of technology— a mechanical ventilator and perhaps a tracheostomy tube if the lungs have failed, an aortic balloon pump if the heart has given out, a dialysis machine if the kidneys don’t work. If you are unconscious and can’t eat, silicone tubing can be surgically inserted into your stomach or intestines for formula feeding. If your intestines are too damaged, solutions of amino acids, fatty acids, and glucose can be infused directly into your bloodstream.
On any given day in the United States alone, some ninety thousand people are admitted to intensive care. Over a year, an estimated five million Americans will be, and over a normal lifetime nearly all of us will come to know the glassed bay of an ICU from the inside. Wide swaths of medicine now depend on the life support systems that ICUs provide: care for premature infants; for victims of trauma, strokes, and heart attacks; for patients who have had surgery on their brains, hearts, lungs, or major blood vessels. Critical care has become an increasingly large portion of what hospitals do. Fifty years ago, ICUs barely existed. Now, to take a recent random day in my hospital, 155 of our almost 700 patients are in intensive care. The average stay of an ICU patient is four days, and the survival rate is 86 percent. Going into an ICU, being put on a mechanical ventilator, having tubes and wires run into and out of you, is not a sentence of death. But the days will be the most precarious of your life.
Fifteen years ago, Israeli scientists published a study in which engineers observed patient care in ICUs for twenty- four- hour stretches. They found that the average patient required 178 individual actions per day, ranging from administering a drug to suctioning the lungs, and every one of them posed risks. Remarkably, the nurses and doctors were observed to make an error in just 1 percent of these actions— but that still amounted to an average of two errors a day with every patient. Intensive care succeeds only when we hold the odds of doing harm low enough for the odds of doing good to prevail. This is hard. There are dangers simply in lying unconscious in bed for a few days. Muscles atrophy. Bones lose mass. Pressure ulcers form. Veins begin to clot. You have to stretch and exercise patients’ flaccid limbs daily to avoid contractures; you have to give subcutaneous injections of blood thinners at least twice a day, turn patients in bed every few hours, bathe them and change their sheets without knocking out a tube or a line, brush their teeth twice a day to avoid pneumonia from bacterial buildup in their mouths. Add a ventilator, dialysis, and the care of open wounds, and the difficulties only accumulate.
The story of one of my patients makes the point. Anthony DeFilippo was a forty- eight- year- old limousine driver from Everett, Massachusetts, who started to hemorrhage at a community hospital during surgery for a hernia and gallstones. The surgeon was finally able to stop the bleeding but DeFilippo’s liver was severely damaged, and over the next few days he became too sick for the hospital’s facilities. I accepted him for transfer in order to stabilize him and figure out what to do. When he arrived in our ICU, at 1:30 a.m. on a Sunday, his ragged black hair was plastered to his sweaty forehead, his body was shaking, and his heart was racing at 114 beats a minute. He was delirious from fever, shock, and low oxygen levels.
"I need to get out!" he cried. "I need to get out!" He clawed at his gown, his oxygen mask, the dressings covering his abdominal wound.
"Tony, it’s all right," a nurse said to him. "We’re going to help you. You’re in a hospital."
He shoved her out of the way— he was a big man— and tried to swing his legs out of the bed. We turned up his oxygen flow, put his wrists in cloth restraints, and tried to reason with him. He eventually tired out and let us draw blood and give him antibiotics.
The laboratory results came back showing liver failure and a steeply elevated white blood cell count, indicating infection. It soon became evident from his empty urine bag that his kidneys had failed, too. In the next few hours, his blood pressure fell, his breathing worsened, and he drifted from agitation to near unconsciousness. Each of his organ systems, including his brain, was shutting down.
I called his sister, his next of kin, and told her the situation. "Do everything you can," she said.
So we did. We gave him a syringeful of anesthetic, and a resident slid a breathing tube into his throat. Another resident "lined him up." She inserted a thin two- inch- long needle and catheter through his upturned right wrist and into his radial artery, then sewed the line to his skin with a silk suture. Next, she put in a central line— a twelve- inch catheter pushed into the jugular vein in his left neck. After she sewed that in place, and an X-ray showed its tip floating just where it was supposed to— inside his vena cava at the entrance to his heart— she put a third, slightly thicker line, for dialysis, through his right upper chest and into the subclavian vein, deep under the collarbone.
We hooked a breathing tube up to a hose from a ventilator and set it to give him fourteen forced breaths of 100 percent oxygen every minute. We dialed the ventilator pressures and gas flow up and down, like engineers at a control panel, until we got the blood levels of oxygen and carbon dioxide where we wanted them. The arterial line gave us continuous arterial blood pressure measurements, and we tweaked his medications to get the pressures we liked. We regulated his intravenous fluids according to venous pressure measurements from his jugular line. We plugged his subclavian line into tubing from a dialysis machine, and every few minutes his entire blood volume washed through this artificial kidney and back into his body; a little adjustment here and there, and we could alter the levels of potassium and bicarbonate and salt, as well. He was, we liked to imagine, a simple machine in our hands.
But he wasn’t, of course. It was as if we had gained a steering wheel and a few gauges and controls, but on a runaway 18wheeler hurtling down a mountain. Keeping that patient’s blood pressure normal required gallons of intravenous fluid and a pharmacy shelf of drugs. He was on near- maximal ventilator support. His temperature climbed to 104 degrees. Less than 5 percent of patients with DeFilippo’s degree of organ failure make it home. A single misstep could easily erase those slender chances.
For ten days, though, we made progress. DeFilippo’s chief problem had been liver damage from his prior operation: the main duct from his liver was severed and was leaking bile, which is caustic— it digests the fat in one’s diet and was essentially eating him alive from the inside. He had become too sick to survive an operation to repair the leak. So once we had stabilized him, we tried a temporary solution— we had radiologists place a plastic drain, using CT guidance, through his abdominal wall and into the severed duct in order to draw out the leaking bile. They found so much that they had to place three drains— one inside the duct and two around it. But, as the bile drained out, his fevers subsided. His need for oxygen and fluids diminished, and his blood pressure returned to normal. He was beginning to mend. Then, on the eleventh day, just as we were getting ready to take him off the ventilator, he again developed high, spiking fevers, his blood pressure sank, and his blood- oxygen levels plummeted again. His skin became clammy. He got shaking chills.
We couldn’t understand what had happened. He seemed to have developed an infection, but our X-rays and CT scans failed to turn up a source. Even after we put him on four antibiotics, he continued to spike fevers. During one fever, his heart went into fibrillation. A Code Blue was called. A dozen nurses and doctors raced to his bedside, slapped electric paddles onto his chest, and shocked him. His heart responded and went back into rhythm. It took two more days for us to figure out what had gone wrong. We considered the possibility that one of his lines had become infected, so we put in new lines and sent the old ones to the lab for culturing. Forty- eight hours later, the results returned. All the lines were infected. The infection had probably started in one line, which perhaps was contaminated during insertion, and spread through DeFilippo’s bloodstream to the others. Then they all began spilling bacteria into him, producing the fevers and steep decline.
This is the reality of intensive care: at any point, we are as apt to harm as we are to heal. Line infections are so common that they are considered a routine complication. ICUs put five million lines into patients each year, and national statistics show that after ten days 4 percent of those lines become infected. Line infections occur in eighty thousand people a year in the United States and are fatal between 5 and 28 percent of the time, depending on how sick one is at the start. Those who survive line infections spend on average a week longer in intensive care. And this is just one of many risks. After ten days with a urinary catheter, 4 percent of American ICU patients develop a bladder infection. After ten days on a ventilator, 6 percent develop bacterial pneumonia, resulting in death 40 to 45 percent of the time. All in all, about half of ICU patients end up experiencing a serious complication, and once that occurs the chances of survival drop sharply.
It was another week before DeFilippo recovered sufficiently from his infections to come off the ventilator and two months before he left the hospital. Weak and debilitated, he lost his limousine business and his home, and he had to move in with his sister. The tube draining bile still dangled from his abdomen; when he was stronger, I was going to have to do surgery to reconstruct the main bile duct from his liver. But he survived. Most people in his situation do not.
Here, then, is the fundamental puzzle of modern medical care: you have a desperately sick patient and in order to have a chance of saving him you have to get the knowledge right and then you have to make sure that the 178 daily tasks that follow are done correctly— despite some monitor’s alarm going off for God knows what reason, despite the patient in the next bed crashing, despite a nurse poking his head around the curtain to ask whether someone could help "get this lady’s chest open." There is complexity upon complexity. And even specialization has begun to seem inadequate. So what do you do?
The medical profession’s answer has been to go from specialization to superspecialization. I told DeFilippo’s ICU story, for instance, as if I were the one tending to him hour by hour. That, however, was actually an intensivist (as intensive care specialists like to be called). As a general surgeon, I like to think I can handle most clinical situations. But, as the intricacies involved in intensive care have grown, responsibility has increasingly shifted to super-specialists. In the past decade, training programs focusing on critical care have opened in most major American and Eu ro pe an cities, and half of American ICUs now rely on superspecialists.
Expertise is the mantra of modern medicine. In the early twentieth century, you needed only a high school diploma and a one- year medical degree to practice medicine. By the century’s end, all doctors had to have a college degree, a four- year medical degree, and an additional three to seven years of residency training in an individual field of practice— pediatrics, surgery, neurology, or the like. In recent years, though, even this level of preparation has not been enough for the new complexity of medicine. After their residencies, most young doctors today are going on to do fellowships, adding one to three further years of training in, say, laparoscopic surgery, or pediatric metabolic disorders, or breast radiology, or critical care. A young doctor is not so young nowadays; you typically don’t start in in de pen dent practice until your midthirties.
We live in the era of the superspecialist— of clinicians who have taken the time to practice, practice, practice at one narrow thing until they can do it better than anyone else. They have two advantages over ordinary specialists: greater knowledge of the details that matter and a learned ability to handle the complexities of the particular job. There are degrees of complexity, though, and medicine and other fields like it have grown so far beyond the usual kind that avoiding daily mistakes is proving impossible even for our most superspecialized.
There is perhaps no field that has taken specialization further than surgery. Think of the operating room as a particularly aggressive intensive care unit. We have anesthesiologists just to handle pain control and patient stability, and even they have divided into subcategories. There are pediatric anesthesiologists, cardiac anesthesiologists, obstetric anesthesiologists, neurosurgical anesthesiologists, and many others. Likewise, we no longer have just "operating room nurses." They too are often subspecialized for specific kinds of cases.
Then of course there are the surgeons. Surgeons are so absurdly ultraspecialized that when we joke about right ear surgeons and left ear surgeons, we have to check to be sure they don’t exist. I am trained as a general surgeon but, except in the most rural places, there is no such thing. You really can’t do everything anymore. I decided to center my practice on surgical oncology— cancer surgery— but even this proved too broad. So, although I have done all I can to hang on to a broad span of general surgical skills, especially for emergencies, I’ve developed a particular expertise in removing cancers of endocrine glands.
The result of the recent de cades of ever- refined specialization has been a spectacular improvement in surgical capability and success. Where deaths were once a double- digit risk of even small operations, and prolonged recovery and disability was the norm, day surgery has become commonplace.
Yet given how much surgery is now done— Americans today undergo an average of seven operations in their lifetime, with surgeons performing more than fifty million operations annually— the amount of harm remains substantial. We continue to have upwards of 150,000 deaths following surgery every year— more than three times the number of road traffic fatalities. 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.
Medicine, with its dazzling successes but also frequent failures, therefore poses a significant challenge: 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.
Excerpted from The Checklist Manifesto by Atul Gawande.
Copyright © 2009 by Atul Gawande.
Published in 2010 by Henry Holt and Company, LLC.
All rights reserved. This work is protected under copyright laws and reproduction
is strictly prohibited. Permission to reproduce the material in any manner or
medium must be secured from the Publisher.
Table of Contents
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
Most Helpful Customer Reviews
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).
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.
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.
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.
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.
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
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.
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.
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
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.
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.
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.
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.
An accessible (but somewhat fluffy) advocacy for simple, standardized practices.
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.
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.
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?
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.
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.
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.
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.
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.
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.
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.
A heartfelt and thoughtful call for simple systematics action to prevent potentially catastrophic failure.