Today we can do amazing things: we can predict hurricanes and tornadoes, we can build skyscrapers of all shapes, and we can save people from heart attacks and severe injuries that would have been fatal a few decades ago.
Yet highly trained, experienced, and capable people regularly make avoidable mistakes. Some can be fatal. After experiencing his own mistakes and observing those of colleagues, Boston surgeon Atul Gawande set out to learn why smart people make avoidable errors and how to prevent them.
The result is The Checklist Manifesto: How to Get Things Right, in which Gawande proposes a simple solution: a checklist. The book chronicles his exploration of the uses and benefits of checklists in many fields, including aviation, construction, and medicine. While not a how-to manual, his book builds the case for checklists and makes a plea for widespread adoption of checklists as a safety net for human fallibility.
He argues that we fail to get simple things right because in numerous professions — for instance, medicine, engineering, finance, business, and government — the level and complexity of our collective knowledge has exceeded the capacity of any individual to get everything right.
Most professions, especially medicine, have traditionally responded to failure by requiring more training and experience. Training of medical personnel, police, engineers, and others is more extensive than ever. But while training and experience are important, expertise can’t eliminate human fallibility. What’s needed is a different strategy for preventing failure that takes advantage of knowledge and experience but also compensates for human flaws. The solution is a checklist.
To understand how easy it is to make mistakes, despite our ability as humans to accomplish amazing things, consider how complex medicine has become as it has advanced.
An Israeli study several decades ago showed that the average ICU patient required 178 actions or procedures a day. We have a greater-than-ever chance to save someone who’s seriously ill, but it requires both deciding the right treatment and ensuring that 178 tasks are done correctly each day. There’s as much chance to harm a patient as to help.
In complex environments, checklists can help to prevent failure by addressing two problems:
Checklists protect against failures because they remind you of the minimum necessary steps by spelling them...
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In the 21st century, we can do things that were unthinkable not long ago. We can predict hurricanes and tornadoes, we can build skyscrapers and buildings of all shapes, and we can save people from heart attacks and severe injuries that would have been fatal a few decades ago.
Yet highly trained, experienced, and capable people regularly make avoidable mistakes. Some can be fatal. After experiencing his own mistakes and observing those of colleagues, Boston surgeon Atul Gawande set out to learn why smart people make avoidable errors and, more importantly, to find a way to prevent them. The result is The Checklist Manifesto: How to Get Things Right, in which Gawande proposes a simple solution: a checklist.
In a 1970s essay on human fallibility, Samuel Gorovitz and Alasdair MacIntyre argued that in some cases we fail due to “necessary fallibility” — because we’re trying to do something humans are incapable of. Much of the universe is unknown to us; there are limits to what we can know and do.
Yet we also fail frequently in areas where we have control. Gorovitz and MacIntyre argued there are two reasons:
To understand how easy it is to make mistakes, despite our ability as humans to accomplish amazing things, consider how complex medicine as become.
The World Health Organization’s international classification of diseases (ninth edition) lists over 13,000 different diseases, syndromes, and injuries. There are treatments for nearly all of them, but there are different, complicated steps for handling each one. Doctors can choose among more than 6,000 drugs and 4,000 medical and surgical procedures.
A Boston clinic affiliated with Gawande’s hospital began with a straightforward goal in 1969: to provide the full range of outpatient services its patients might need throughout their lives. Delivering that care led to the construction of more than twenty facilities and the employment of six hundred doctors and one thousand other health professionals covering fifty-nine specialties.
In a typical year, each doctor at the clinic evaluated an average of two hundred and fifty different diseases and conditions in patients who had more than 900 other medical issues. Each doctor prescribed some three hundred medications, ordered more than a hundred different tests, and performed an average of...
In complex environments, checklists can help to prevent failure by addressing two problems:
1) Our memory and our attention to detail fail when we’re distracted by more urgent matters. For instance, if you’re a nurse, you might forget to take a patient’s pulse when she’s throwing up, a family member is asking questions, and you’re being paged.
Forgetfulness and distraction are especially risky in what engineers call all-or-none processes, where if you miss one key thing, you fail at the task. For instance, if you go to the store to buy ingredients for a cake and forget to buy eggs, you can’t make the recipe because it wouldn’t work without eggs. The consequences are more serious if a pilot misses a step during take-off or a doctor misses the key symptom.
2) People have a tendency to skip steps even when they remember them. In complex processes, certain steps don’t always matter, so people may play the odds and skip them. For instance, if measuring all four of a patient’s vital signs (pulse, blood pressure, temperature, and respiration) only rarely detects a problem, you might become lax about checking everything.
Checklists protect against such failures because...
The successful experiences of using checklists in aviation decades ago suggest they could be applied widely. They protect even the most experienced from making mistakes in a whole range of tasks. They provide a mental safety net against typical human lapses in memory, focus, and attention to detail.
Professors Brenda Zimmerman and Sholom Glouberman, who study complexity, defined three kinds of problems: simple, complicated, and complex.
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A striking feature of the building industry’s strategy for handling myriad steps correctly in complex situations is empowerment.
That’s not the way complexity and risk are usually handled elsewhere. Most authorities centralize power and decision-making via a command-and-control model. That’s one way of using checklists: to dictate instructions to workers down the line so they do things in a prescribed way.
A construction schedule checklist works that way — but it’s paired with the submittal schedule (the one that establishes communication processes), which is based on a different philosophy of power for solving non-routine problems. The submittal schedule pushes decision-making out from the center. People have the ability to make their own judgments based on their experience and expertise, but they’re required to communicate with others and take responsibility.
For example, because determining whether every detail is correct requires more knowledge than any one person can possess, building inspectors mostly make sure that builders have the right checks in place and require them to sign affidavits attesting that they have ensured the structure meets code requirements....
In 2006, the World Health Organization (WHO) asked Gawande to organize a group to solve a problem: Surgery was increasing rapidly worldwide, but surgical patients were getting unsafe care so often that surgery was a public danger. WHO sought a global program that would reduce avoidable harm and deaths from surgery.
Data from 193 countries showed that the volume of surgery worldwide had skyrocketed by 2004. Surgeries exceeded totals for childbirth, but the death rate for surgery was ten to one hundred times higher than for childbirth. At least seven million people a year were disabled by surgery, and one million died.
The growth was due in part to improved economic conditions, which increased people’s longevity and therefore their need for surgeries. Health systems were greatly increasing the number of surgical procedures performed and the types of surgeries. There were more than 2,500 different surgical procedures. Safety and quality of care for surgical patients was becoming a big issue everywhere.
Surgery is often life-saving, even when performed under dire or substandard conditions. But failures leave millions disabled or dead. In the U.S. alone, when Gawande began the...
While it should be simple to use, developing an effective checklist isn’t a simple task. It requires analysis, real-world testing, and revision.
Daniel Boorman, flight desk designer for Boeing, is an expert at developing checklists. He’s analyzed thousands of crashes and mishaps in an effort to figure out how to create checklists that prevent human errors.
Boorman’s checklists for Boeing aircraft fill a thick spiral-bound handbook with tabs. Yet each checklist is brief, consisting of a few lines on a page in large, easy-to-read type. Each applies to a different situation; together they encompass a range of scenarios. At the beginning of the notebook are what pilots call “normal” checklists for routine operations — for instance, steps to take before starting the engines. They’re followed by “non-normal” checklists for emergency situations such as engine failure, smoke in the cockpit, or an insecure door.
Over two decades, Boorman has learned how to make checklists that work. There are key differences between bad and good checklists.
Bad checklists are:
With information from Boorman on how to create an effective checklist, Gawande and his team created and began testing a Surgical Safety Checklist for WHO.
They chose a Do-Confirm approach to give people greater flexibility in performing their tasks, but had them stop at key points to confirm they hadn’t missed any steps. When researchers tested the checklist in a simulated surgery, they realized they hadn’t designated who was supposed to pause things and launch the checklist. They decided to have the circulating nurse call the pause rather than the surgeon, to send the message that everyone is responsible for the overall well-being of the patient in surgery.
They had a team in London try the checklist, then one in Hong Kong, and continued to improve it. The final WHO checklist listed 19 checks with three pause points and it took two minutes to go through. The checks were divided as follows:
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If someone discovered a new drug that reduced complications from surgery as much as the checklist did in the pilot study, it would be rushed to the market. Competitors would start making better versions. If the checklist were a medical device, every surgeon would want it.
Since the results of the WHO checklist were published in early 2009, more than a dozen countries pledged to implement checklists. By the end of 2009, about 10 percent of U.S. hospitals and 2,000 worldwide had implemented or pledged to implement the checklist.
However, since this early enthusiasm, it’s proven more difficult to persuade doctors to change their Lone Ranger culture to one of teamwork, starting with checklists. If they did, good checklists could become as important for them as stethoscopes (which, unlike checklists, have never been proven to improve patient care).
Tom Wolf’s book, The Right Stuff, chronicles the passing of the maverick test pilot culture.
Being a test pilot was extremely dangerous when the job began — pilots needed courage and an ability to improvise: the right stuff. But as knowledge and complexity of flying grew, and pilots began using checklists and flight...
In 2007 as soon as the Safe Surgery Checklist took shape, Gawande began using it in his surgeries. Hardly a week went by without the checklist enabling the team to catch something they would have otherwise missed.
For instance, in one week, there were catches in five cases, including:
Creating a checklist involves three phases, each with key steps, including the following.
Establish clear, concise objectives. Each task you include should be:
Also, include items to improve communication among team members. Involve...
Checklists help to prevent mistakes because: 1) our memory and attention to detail tend to fail when we’re distracted by more urgent matters and 2) we have a tendency to skip steps even when we remember them. Consider how you might use checklists in your everyday life.
Think of an important task you do regularly, such as changing the oil or doing other vehicle maintenance, that requires multiple steps. Think of a time when you forgot or skipped a step. What was the result?
Checklists are widely used in the construction and aviation industries. Also, the book describes uses in medicine, finance, and in the restaurant industry. The author argues they’re applicable in virtually any field, but are underutilized. Consider how you might use checklists to improve your effectiveness at work.
Do you or anyone else at work use checklists in your occupation to improve outcomes for customers? If not, what are some ways they could be incorporated? What would the benefits be?
Checklists should be short, clear, and contain the “killer” steps (the ones with the greatest consequences if you miss them) as well as routine steps you might miss. Create a checklist to increase the effectiveness of your routines at work or at home.
Think of a task that you or others perform at home or at work that is error-prone (if you like, you can use the example you chose for one of the previous exercises). Describe what a checklist for this task would look like — define the task, determine the pause points or logical breaks in the workflow, and the steps to be taken after each pause.