The Checklist Manifesto: How to Get Things Right by Atul Gawande

The book opens with a frightening war story surrounding the surgical removal of a
patients stomach cancer. Near the end of the operation, the patients heart inexplicably
stopped beating. After going through a multiple of potential causes, a senior
anesthesiologist jogs the memory of the anesthesiologist on duty who realizes that he
gave an extra dose of potassium. Upon further investigating the dosage, he discovered
that the dose was almost one hundred times the recommended amount. Only after a series
of drastic measures was the operating team able to revive the patient, having nearly killed
him. Fortunately, the man recovered, almost as if the whole episode had never occurred.
Even enhanced by technology, our physical and mental powers are limited. Much of the
world and universe is and will remain outside of our understanding and control. (8)
Part of the implementation of checklists will be the realization that all people are
imperfect and that mistakes will happen unless preventative measures are put in place.
Know-how and sophistication have increased remarkably across almost all our realms of
endeavor, and as a result so has our struggle to deliver on them. In almost any endeavor
requiring mastery of complexity and of large amounts of knowledge, you will see
mistakes. Failures of ignorance can be forgiven, but if the knowledge exists and is
applied incorrectly, it is difficult not to be infuriated.
The rate of failure has remained significant despite the increases training and practice.
Failures are not necessarily and indication of individual ability.
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 (13)
Consider the use of intensive care units in hospitals. The average patient in the ICU
requires 178 actions to be taken on his or her behalf per day. Currently, nurses make
errors in only 1 percent of these actions, but that still amounts to nearly 2 errors per
patient per day. Intensive care will only succeed when the odds of doing harm are low
enough for the odds of doing good to prevail.
More than 150,000 deaths from surgery annually, more than 3 times the number of road
traffic fatalities. 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. (31)
Substantial parts of what specialists do nowadays are too complex for them to carry out
reliably from memory alone. Many believe that their jobs are too complicated or
advanced to reduce to checklists. Mapping out the proper steps for every case is not
possible, and many are skeptical that a piece of paper with a bunch of little boxes would
improve matters.

Example of B-17 bomber that was the clear choice for a government-contracted plane
crashed a few minutes after takeoff due to pilot error. Checklists allowed future pilots to
pilot the plane successfully.
In one hospital, a simple six-process checklist and empowering nurses to enforce the
process resulted in drop of the line infection rate from 11% to 0%. Further checklists to
ensure proper care (pain checks, medication prescriptions, patient bed positioning)
resulted in similar improvements. These checks helped with memory recall and clearly
set out the minimum necessary steps in a process.
Checklists given to people with less power allow for more time to be spent on keeping
track of records and accountability.
A big part of overall success is the minimization of errors. In highly complex processes,
the smallest errors can negate much more impactful factors.
Checklists provide a kind of cognitive net. They catch mental flaws inherent in all of us
flaws of memory and attention and thoroughness. And because they do, they raise wide,
unexpected possibilities.
Building designers, engineers and constructors long ago had to specialize and implement
checklists in their operations in order to reduce the margin for error. Gawandes tour of a
new hospital facility being built opened his eyes to a line-by line, day-by-day listing of
every building task that needed to be accomplished, in what order, and when with
multiple color-coded sheets. The checklist corresponded with a computer program from
which updated sheets were created. The construction schedule was essentially a long
checklist.
Checklists are drawn up by a group of people representing each trade involved in a
process. Then, the whole checklist is sent to the subcontractors and other independent
experts so they can double-check that everything is correct, that nothing has been missed.
Realize that situations will arise that are not included in the checklist. Also, consider a
checklist for communication to make sure that all parties are in sync. This is especially
useful for making sure that people work together to solve unforeseen problems that arise.
Communication allows for multiple pairs of eyes to focus on a problem and for a
consensus solution to be reached. Man is fallible, but maybe men are less so. (67)
Ideally, future issues are flagged automatically by software, which alerts critical parties to
review the issue to avoid problems.
Building checklists exposed the benefit of decentralizing the power in decision making.
Give people the room to adapt, based on their experience and expertise. All you ask is
that they talk to one another and take responsibility. Encourage excessive communication
among all parties that have the potential to contribute. Building inspectors, too, follow a

similar approach. They disperse power and responsibility. They make certain that
builders have the proper checks in place and then have them sign affidavits stating that
they themselves have complied with the building codes.
Wal-Mart has passed down a simple edict to store managers that resulted in their
surprisingly positive handling of Hurricane Katrina: A lot of you are going to have to
make decisions above your level. Make the best decision that you can with the
information thats available to you at the time, and, above all, do the right thing. (76)
Wal-Mart managers made the decision to give away inventory to the communities long
before FEMA could even fathom how to approach the situation. The employees gave
away prescription medication, set up free check cashing, opened temporary clinics, and
delivered 2500 trailer loads of emergency supplies to shelters.
One goal of checklists is to make the reliable management of complexity a routine. That
routine should include freedom and discipline, craft and protocol, specialized ability and
group collaboration. For check lists to help achieve that balance, they have to supply a set
of checks to ensure the stupid but critical stuff is not overlooked, and they supply another
set of check to ensure that people talk and coordinate and accept responsibility while
nonetheless being left the power to manage the nuances and unpredictability the best they
know how. (79)
Consider restaurantsat the heart of every meal is a checklist: the recipe.
Following the recipe to a T is essential to consistent food taste and quality.
Recipes are not always static, sometimes there will be additions made by the chefs
to improve the dish and at others there could be a complete revamp. Orders were
carefully recorded by table and seat number with notes for any special needs such
as food allergies. These orders were passed on and confirmed in the kitchen. Even
before the restaurant opens, the employees go through a checklist of things
needed to be done to open the restaurant. Every employee speaks and everyone
collaborates to come up with solutions to problems. One final check (85) was to
have each plate reviewed by the owner or sous chef before it left the kitchen to
check for presentation, accuracy, and even taste.
Consider the CDC soap study in Karachi, Pakistan. By implementing a simple checklist
for soap usage (when, how often), the incidence of a number of very common diseases
dropped by 50%. Providing free soap was one part of the equation, but the simple and
easy to follow guidelines/checklist ensured that people utilized the directions and were
able to follow along accordingly.
Cleared for Takeoff checklist implementation: nurses put a reminder (metal tent with
cleared for takeoff engraved on it) over scalpel before each surgery, mandated verbal
review of each line on the checklist between surgeon and nurse before surgery is started.
The result was an improvement in patient care, and with time, surgeons realized that the
operation would be held up unless the checklist was carefully completed.

Another key to process improvement is not just the training of specialists, but the
collaboration of multiple people to ensure that nothing falls through the cracks and to
minimize the unexpected variables that arise. Research has also shown that introducing
oneself at the beginning of a procedure enhances a groups ability to work together. Also,
encouraging each person to speak before a procedure begins allows for risks to be
exposed and potential solutions to be discussed. Checklists have proven to reduce errors
dealing with paperwork, medications,
Checklist simplicity can be achieved by breaking down a large checklist into smaller
versions for different tasks or scenarios. Pilots have these for daily routines and nonnormal events including smoke in the cockpit, different warning lights, a dead radio, etc.
Good checklists are precise. They are efficient to the point and easy to use even in the
most difficult situations. They do not spell out everything a checklist cannot fly a plane.
Instead, they provide reminders of only the most critical and important steps the ones
that even the highly skilled professionals using them could miss. Good checklists are,
above all, practical (120)
Checklists can help manage a complex problem or manage a complex machine, they can
make priorities clearer and prompt people to function better as a team, but they can not
make anyone follow them by themselves.
Checklists need to be ingrained in a persons training and the checklists should be proven
to have a positive benefit.

Process for Creating a Checklist:

1.) Define a clear pause point at which the checklist is supposed to be used.
2.) You must decide whether you want a do-confirm checklist or a read-do checklist
a. With a do-confirm team members perform their jobs from memory and
experience, often separately. But then they stop. They pause to run the
checklist and confirm that everything that was supposed to be done was
done.
b. With a read-do checklist, people carry out the tasks as they check them off
its more like a recipe.
3.) The checklist cannot be lengthy, keep it at 5-9 items
a. If it takes more than 90 seconds, it will encourage short cuts
4.) Focus on the killer items
a. Try to find data to establish what these killer items are
5.) The wording should be simple and exact
6.) The look of the checklist matters it should fit on one page, be free of clutter and
unnecessary colors, should use uppercase and lowercase letters for the ease of
reading.
7.) Checklist needs to be tested in the real world and altered continually
8.) Find ways to force the user to pay attention and truly think about each check

9.) Checklist text should be clear and concise

10.)
Realize that certain things will have to be omitted from the checklist to
ensure it meets a reasonable length requirement, but make sure that omitted items
are the least frequent to cause issues or be forgotten.
11.)
The checklist should be started by a subordinate to spread responsibility
and the power to question. Doing so would also reduce any lack of focus for the
surgeon.
12.)
Consider segmenting the checklist into stages to enhance focus and build
repetition.
13.)
Checklists might need to be adapted for certain groups depending on the
way their processes are structured
14.)
Put a publication date on a checklist
Checklists are not how-to guides, but quick and simple tools aimed to buttress the skills
of expert professionals.
An alteration in a checklist can function to change a fundamental process across a wide
range of operators or users. Consider the change in pilot procedure when power to
engines is lost after the crash of a British Airways flight from Beijing to London. Once
the cause was determined, pilots all around the world were able to come up to speed
within 30 days, because their checklists were altered to reflect the new procedure. It has
taken doctors over ten years to adopt common practices regarding respiratory infections.
The increase in time to adopt is not a result of laziness or unwillingness, but rather a
result of the necessary knowledge not being translated into a simple, usable, and
systematic form. (133) Changes in medical best practices tend to be revealed in lengthy
journals and in the medical curriculum for new medical students that may not start
practicing for over ten years.
During a study of 8 global hospitals in both developed and underdeveloped countries,
Gawande found that basic surgical safe checks were missed at least 6% of the time and
on average one was missed in a startling 2/3 of patients, whether in rich countries or poor
(145) The later implementation of the checklist involved a major cultural change, as well
a shift in authority, responsibility, and expectations about care and the hospitals
needed to recognize that.
They key is not just ticking boxes, but embracing a culture of teamwork and discipline.

Finance Applications:
Your brain is wired to attach itself to evidence that confirms your initial hunch and
dismisses the signs of a downside. In the midst of a bear market, one will similarly
overestimate the dangers.

When analyzing a company, stop and confirm that youve asked yourself whether the
revenues might be overstated or understated due to boom or bust conditions. (166)
Example was Cort, the furniture leasing company that was leasing to technology
companies during the dot-com bubble.
Confirm that you have carefully analyzed the past 10 years of financial statements. Check
that youve read the footnotes on the cash flow statements. Review key management
risks. Review the fine print of the companys mandatory stock disclosures.
Financial firms found that checklists functioned to cut down work on companies that
would be eliminated from a list of potential investments anyway. Checklists can function
as a screening tool for searching out potential investments. The surprising thing is that
most investors have decided not to take a more orderly, checklist-driven approach.
Gawande suggests that it somehow feels beneath us to use a checklist, an embarrassment.
It runs counter to deeply held beliefs about how the truly great among us those we
aspire to be handle situations of high stakes and complexity. The truly great are daring.
They improvise. They do not have protocols and checklists. Maybe our idea of heroism
needs updating. (173).

US Airways Flight 1549

The media decided to give the glory to Captain Chelsey B. Sullenberger III, while he
maintained that being able to land the plane in the Hudson was actually a crew effort.
Gawande highlights that the two pilots had extensive experience, which in many
professions would not necessarily result in optimal cooperation, but the checklist process
requires a strong degree of collaboration pre-flight. Despite the fact that not one crew
member had experienced an airplane accident, they still ran through their checks. Their
expectation of something going wrong was far lower than is expected in medicine,
finance, or law.
When geese were sucked into the jet engines on Sullenbergers flight, his and his
colleagues reaction was swift, immediate, and organized. The preparation had made them
a team. Sullenberger would look for the nearest, safest possible landing site. Skiles would
go to the engine failure checklists and see if he could relight the engines. The plane had
about 3.5min of glide and during that time, Skiles (copilot) needed to make sure hed
done everything possible to relight the engines while also preparing the aircraft for
ditching if it wasnt feasible. When the two pilots decided that the glide down to the
water was their best option, the onboard control system played a crucial role in
maintaining ideal positioning so that Sullenberger could focus on finding a landing site
near ferries and keeping the wings level as the plane hit the waters surface. The flight
attendants remained composed during the entire episode and managed a complete
evacuation of the aircraft in under 3 minutes. Even after the crash, Skiles ran the
evacuation checklist to ensure that potential hazards were dealt with.

In this situation, the pilots showed an ability to adhere to vital procedures when it
mattered most, to remain calm under pressure, to recognize where one needed to
improvise and where one needed not to improvise. They understood how to function in a
complex and dire situation. They recognized that it required teamwork and preparation
and that it required them long before the situation became complex and dire. (182)
Professions need to work on including discipline in following prudent procedure and in
functioning with others.
One essential characteristic of modern life is that we all depend on systems on
assemblages of people or technologies or both and among our most profound
difficulties is making them work. You see, it is not enough to simply optimize parts. You
must figure out how to make the parts work well together and how to incorporate the
system into daily practice.

Finally, the last example is his recent application of the checklist and its one glaring
success. During the checklist for a rare but likely to be successful surgery, Gawande
mentioned a theoretical amount of blood that could be lost and the nurse took this as an
indication to ready a larger than normal quantity of blood just in case. Low and behold,
when Gawande tore the patients vena cava by mistake, the extra blood and cohesiveness
of the crew saved his life, and only barely.