The Checklist Manifesto: How to Get Things Right

The Checklist Manifesto: How to Get Things Right is a 2009 book by Atul Gawande. The book provides insights into surgical care and the problems that often arise in the field, and offers the checklist as a simple, yet powerfully effective solution. Gawande includes a significant amount of data in the book, some of which is alarming for readers not involved in his profession as a surgeon. He also interviews many professionals from different industries throughout the book, seeking to understand how checklists function in these industries, and examining why his profession is slow to adopt the simple remedy.

This guide is based on the 2009 Kindle Edition.

Summary

The introduction to The Checklist Manifesto: How to Get Things Right begins with two stories from a friend of Atul Gawande’s, a surgeon named John. Both stories describe relatively predictable, routine procedures that became nearly catastrophic: Both patients whom John was treating nearly died, and only through urgency did they survive. John is able to pinpoint both dramatic shifts to a simple mistake. These two stories frame the rest of the book. Gawande considers if the mistakes that were made were avoidable, and concludes that they were. He then proposes a scenario in which oversights and mistakes of ineptitude can be prevented routinely. He posits the checklist as a strong line of defense against such mistakes.

In Chapter 1, Gawande explores the nature of mistakes, examining the categories of mistakes and what these look like in a real-world surgical setting. He describes the conditions of an intensive care unit (ICU), where the unpredictable is the norm rather than the exception. He elaborates on what being a surgeon working with ICU patients demands, and the complexity of performing under such conditions when every patient is different. This stymies the often one-size-fits-all approach to ICU treatment. Gawande shares a personal experience, describing a patient interaction that went wrong in an unforeseen way. He readily accepts that human beings are fallible, and because surgery and critical care are human endeavors, mistakes will likely always happen. However, he also underscores the difference between mistakes that can be avoided and those that can’t.

In Chapter 2, Gawande discusses the creation of the B-17 bomber—and its first flight ending in failure. The failure was caused by a simple mistake made by the original pilot. This error was what ultimately led to the flight checklist concept that all pilots and airlines now follow. Gawande examines the reasons why humans make mistakes from a psychological standpoint: In general, most mistakes committed in complex circumstances stem from faulty memory. In conclusion, the use of a guidance system such as a checklist can help mitigate lapses in memory.

In Chapter 3, Gawande visits a construction site. While there, he is given a behind-the-scenes look into the industry. He meets with Joe Salvia, whose firm has been tasked with the construction of a building in Boston. Gawande also meets with a project manager named Finn O’Sullivan. Both Salvia and O’Sullivan share their own thoughts on why using a checklist at a construction site is useful. Gawande learns that almost all aspects of construction rely on a checklist, including the use of a “submittal schedule” that lists unexpected things that occur at a job site. Everyone from laborer to foreman is encouraged to submit things that are out of the ordinary or unexpected. The enterprise offers important insight into the importance of communication in complex environments.

In Chapter 4, Gawande examines the American government’s failure to adequately respond to citizens impacted by Hurricane Katrina in 2005. Part of this failure stemmed from an outdated top-down command structure; the centralization of authority slowed recovery efforts. By contrast, Wal-Mart gives license to their store managers to make their own decisions. This decentralization of authority helped Wal-Mart make more of an immediate impact than the federal government in the aftermath of the tragedy. Gawande then discusses his behind-the-scenes look into Rialto, a fine-dining establishment in Boston. There, he witnesses how adherence to protocol helps foster collaboration and teamwork.

In Chapter 5, Gawande describes his involvement with the World Health Organization (WHO). At the time, the WHO had been studying data and became alarmed at what they perceived as a growing crisis in medicine: the increase in surgical complications worldwide. Gawande presents data to support the WHO’s suspicions. He discusses the initial conference in Geneva where experts like him assembled to talk about the problem and possible solutions. With limited resources, he looks into similar situations and discovers the work of public health expert Stephen Luby, who successfully applied a public health intervention in Pakistan. Luby convinced health-based corporation Proctor & Gamble to donate soap to impoverished areas in Pakistan, the idea being that improved hygiene would help mitigate spread of disease. The initiative was a success, and it was due in large part to soap instructions—a checklist of sorts.

In Chapter 6, Gawande visits Dan Boorman. Boorman is the man primarily responsible for the development and modification of all flight manuals and checklists for aerospace manufacturer Boeing. From Boorman, Gawande learns the craft of making a checklist—specifically, the characteristics of good checklists and bad ones. Boorman also gives Gawande the opportunity to use a flight simulator, so he can experience a pilot’s sense of urgency.

In Chapter 7, Gawande takes what he learned from Boorman and begins implementing his own checklist. He creates a simulation in which team members act as though they are working on a real surgery. However, Gawande discovers issues with his checklist. He continues to work on it and eventually implements it as part of the WHO’s safe surgery initiative. During the pilot study, he and his team chose eight different hospitals from around the world. They first studied these hospitals under current conditions, and found many problems and a high rate of complications post-surgery. But after implementing Gawande’s checklist for three months, there was a significant reduction of complications. This was momentous for Gawande, as his idea of using checklists to help reduce mistakes was validated.

In Chapter 8, Gawande explores some of the reasons why people in his field are reluctant to embrace something as simple as a checklist. Generally, he sees the medical profession as being slow to leave behind preestablished methods. He notes outdated structures, and suggests that ego gets in the way of progress. As a rebuttal against ego, Gawande closes Chapter 8 with a retelling of a famous aviation incident—the “miracle on the Hudson.” He discovers that contrary to the popular myth, it wasn’t just the work of one man, Chesley “Sully” Sullenberger, that saved the failing plane. Rather, it was the work of the entire crew that saved the lives of all 155 passengers. It was the crew’s discipline and willingness to adhere to protocol that ultimately averted catastrophe.

Gawande concludes the book with an anecdote from his own practice. He discloses that during a surgery to remove a tumor, he inadvertently cut the patient’s vena cava. This caused immediate and tremendous blood loss, and likely would have killed his patient. However, because the surgical team used their pre-surgery checklists, they were prepared for the blood loss, and the man survived.