PDF Summary:The Checklist Manifesto, by Atul Gawande

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Then a nurse noticed his condition was deteriorating. They began life-saving measures and rushed him immediately to the operating room, where they discovered that the man’s stab wound went 12 inches into his body, right into the aorta. With great effort, they managed to save him.

In the process of assessing the patient, the team had gotten almost everything right, but they’d forgotten to ask what he’d been stabbed with, which would have indicated the severity of the injury. A party-goer dressed as a soldier had stabbed him with a bayonet.

In another case, the same surgeon was removing a cancer of the stomach when, about halfway through the procedure, the patient’s heart stopped. The team couldn’t find any cause as they worked to resuscitate him and called for additional personnel and equipment. A senior anesthesiologist who’d been in the room earlier, before the patient had been put to sleep, arrived to help. He asked the attending anesthesiologist if he’d done anything additional since they’d last spoken. The doctor said yes, he’d given the patient potassium when lab reports arrived showing his levels were too low.

When the team dug the IV bag out of the trash, they...

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An Israeli study several decades ago showed that the average ICU patient required 178 actions or procedures a day. We have a greater chance than ever before to save someone who’s seriously ill or injured, but it requires both deciding the right treatment and ensuring that 178 tasks, encompassing various individual steps, are done correctly each day. There’s as much chance to harm a patient as to help. For instance, with all the tubes required, there are myriad ways to introduce infection. In fact, about half of ICU patients end up with a serious complication.

An increasing number of training programs focus on critical care; about half of all hospitals now have intensive care specialists, called intensivists. But with the increasing complexity of medicine, even specialization can’t keep up. So, in addition to specialists, we have superspecialists, who study and practice one thing, like laparoscopic surgery or pediatric genetic diseases. They have greater knowledge and ability to handle the complexities of a particular job, but they haven’t managed to avoid making mistakes.

Surgery is perhaps the most specialized area in medicine. An operating room has an array of...

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Nonetheless, the Army bought a few Model 299s as test planes and a group of test pilots studied how to prevent future pilot errors. Instead of focusing on requiring longer training, they came up with a pilot’s checklist. Flying up to that point had not been especially complicated, but flying the new plane required too many details to be left to memory.

The test pilots made their checklist simple, clear, and concise — it fit on an index card — with step-by-step checks for takeoff, landing, and taxiing. Using the checklist, pilots went on to fly the bomber, which became the B-17 Flying Fortress, 1.8 million miles without incident. The Army ordered 13,000, and the bomber gave the allies a big air advantage in World War II.

Checklists have become essential in aviation, averting problems and accidents. In notebook and electronic forms, they’re a standard and crucial part of pilot training and aircraft operation.

Medical Checklists

In medicine, the four vital signs mentioned above (pulse, blood pressure, temperature, and respiration) have become an important regular check on how a patient is doing. Missing one can be dangerous.

Medical practitioners didn’t consistently...

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But can checklists be used to address complicated or complex problems, such as ICU work, where there are many tasks performed by multiple people, dealing with individual patients with individual and complex problems? Medicine encompasses all three types of problems — simple, complicated, and complex. It’s important to get basic things right, while allowing skill, judgment, and ability to react to the unexpected.

The medical profession could learn from the construction industry, which handles the design and construction of huge and complicated structures with the help of sophisticated checklists addressing the full range of problems.

Demise of the Master Builder

People used to hire master builders, who designed, engineered, and oversaw the construction of large and small projects from start to finish. For instance, master builders built Notre Dame and the U.S. Capitol building.

However, by the mid-20^th-century master builders became obsolete because one person alone couldn’t master the advances occurring at every stage of the construction process. Architectural design and engineering design became separate specialties. Other specialties and...

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But by afternoon the levees had been breached and 80 percent of the city was flooded; 20,000 people were stranded at the Superdome, 20,000 were at a convention center, and another 5,000 had been deposited on an overpass by rescue helicopters. Tens of thousands were stranded in attics and on rooftops.

The government’s command-and-control system became overwhelmed, with too many decisions to make and too little information available. But authorities clung to the traditional model. They argued with state and local government officials over the power to make decisions, resulting in chaos. Supply trucks were halted and requisitions for buses were held up while local transit buses sat idle.

Wal-Mart executives, however, took the opposite approach from command and control. Recognizing the complexity of the circumstances, CEO Lee Scott announced to managers and employees that the company would respond at the level of the disaster. He empowered local employees to make the best decisions they could.

Within 48 hours, employees had gotten more than half the 126 damaged stores up and running, and they began providing help wherever they saw needs — for instance, distributing diapers,...

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The health worker provided soap donated by Proctor & Gamble along with simple guidelines describing six situations in which people should use it and instructions on hand-washing techniques. The soap was a behavior-change vehicle. People appreciated getting the free soap, even though some already had their own own soap. They also liked its scent and a significant number followed the instructions, which were basically a checklist. The incidence of diarrhea among children fell 52 percent. The incidence of pneumonia fell 48 percent and bacterial skin infections fell 35 percent.

The successful soap project was simple, measurable, and widely applicable.

Columbus Children’s Hospital

In 2005, Columbus Children’s Hospital developed a checklist to reduce surgical infections, one of the most common complications of surgery in children. A key to avoiding infections is giving an antibiotic within sixty minutes before the surgeon makes an incision. However, this step was often missed — the hospital’s records showed that a third of pediatric appendectomy patients didn’t get the antibiotic at the right time.

So the hospital’s director of surgical administration designed a...

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2) Decide whether to create a Do-Confirm list or a Read-Do list.

To use a Do-Confirm checklist, team members perform their jobs from memory. Then they stop and go through the checklist and confirm that they completed every item on the checklist. In contrast, to use a Read-Do checklist, people carry out each task as they check it off, like a recipe.

(Shortform note: Choose the type of checklist that makes the most sense for the situation. For instance, a Read-Do list could be used when the sequence needs to be exact or the entire effort will fail, like in operating machinery or listing emergency tasks. A Do-Confirm list gives more freedom and is allowable when the stakes are lower, and a forgotten step can be done later out of sequence.)

Once you’ve chosen which type of checklist you’re creating, follow these guidelines:

• Keep the checklist short, typically five to nine items, which is the limit of short-term memory. After 60 to 90 seconds, a checklist becomes a distraction from other things. People are likely to skip or miss steps.
• Focus on the “killer” items or steps that are most dangerous to miss but that are still sometimes overlooked.
• ...

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They began implementing the checklist in the pilot hospitals in spring 2008. To help get buy-in, they provided each hospital with its failure data to show what the list was trying to address. They presented the checklist as a tool for people to try in hopes of improving their results.

Use of the checklist was well underway within a month and they began hearing encouraging stories. For instance:

• In London, the before-incision part of checklist caught a wrong-size prosthetic knee about to be used as a replacement.
• In India, surgical staff discovered a flaw in their system: they were giving the antibiotic too soon. Frequent delays in the operating schedule meant it had worn off by the time surgery started, so they changed their system.
• In Seattle, they caught problems with antibiotics, equipment, and overlooked medical issues. They also found that going through the list helped the staff respond better if an unexpected problem came up — they worked better as a team.

Three-Month Results

The results after just three months exceeded researchers’ hopes and expectations:

• Rates of major complications for surgical patients in all eight hospitals fell by 36...

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But Sullenberger repeatedly emphasized that it was a crew effort. Many factors contributed to the “miracle on the Hudson”: procedures and checklists, the fly-by-wire computer system that controlled the airplane’s glide to the water, the copilot, and the cabin crew who handled the evacuation. Success was as much a result of teamwork and adherence to procedure as it was of skill and coolness under pressure.

Here’s how events unfolded. Sullenberger and First Officer Jeffrey Skiles, equally experienced pilots, were flying together for the first time. To begin with, they ran through their checklists and introduced themselves to each other and the cabin crew. They held a briefing, discussing the flight plan, potential concerns, and how they’d handle problems. They created a team, ready for the unexpected, which occurred ninety seconds after takeoff when the plane collided with a flock of geese. Two engines were each hit by at least three geese and immediately lost power.

Sullenberger made two key decisions almost instinctively: to take over flying the airplane and to land in the Hudson River. He knew the plane had too little speed to make it back to La Guardia or to...

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• Sans serif.
• Upper and lower case.
• Large enough to be read easily.
• Dark on a light background.

Finalizing

• Test the checklist with front-line users (in either a real or simulated situation).
• Revise it in response to repeated trial runs.
• Make sure it fits the workflow.
• Ensure the checklist can be run in a relatively short amount of time.
• Plan for regular review and revision.