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

“For nearly all of history, people’s lives have been governed primarily by ignorance,” writes Dr. Gawande.

But sometime over the last several decades–and it is only over the last several decades–science has filled in enough knowledge to make ineptitude as much our struggle as ignorance.

In particular, the practice of medicine and especially surgery has improved beyond all imagination, but the discovery and accumulation–and dissemination–of so much research has overwhelmed O.R. teams to the point that too many patients die from what Gawande calls “the stupid stuff,” like the giving of antibiotics prior to surgery. This should be automatic and most of the time it is, but O.R. are not calm, quiet places and neither are the hospitals they are in. Emergencies are commonplace, doctors and nurses get distracted, and mistakes happen.

So Gawande looks at how other professions prevent mistakes, including high rise construction, aviation, and even mutual fund managers. It turns out they all use…checklists.

On an initial test flight in 1935, the B-17, aka the Flying Fortress, crashed and killed two of its five crew.

The Boeing model was deemed, as a newspaper put it, “too much airplane for one man to fly.” The army air corps declared Douglas’s small design the winner. Boeing nearly went bankrupt.

So a group of pilots get together and what do they do? They create a checklist. Anyone who’s ever been on a plane has seen the pilots holding those plastic covered lists and if you’re sitting far enough forward you can hear them running them down. The pilot’s checklist has been instrumental in saving literally thousands of lives in airplane accidents, like United 811 when the cargo door blew off en route from Honolulu to New Zealand in 1989 and including US Airways 1549, aka The Miracle on the Hudson

The pilots’ preparations had made them a team. Sullenberger would look for the nearest, safest possible landing sit. Skiles would go to the engine failure checklists to see if he could relight the engines…In the end, Skiles managed to complete a restart attempt on both engines, something investigators later testified to be “very remarkable” in the time frame he had–and something they found difficult to replicate in simulation.

In conjunction with WHO, Gawande decides to make a checklist for ORs. It is an abysmal failure, too long, too complicated, during the test drive in his own O.R. everyone including the patient hates it.

By the end of the day, we had stopped using the checklist. Forget making this work around the world. It wasn’t even working in one operating room.

So he goes to Boeing, The Checklist Factory (the chapter title), and consults Dan Boorman, the guy in charge of developing checklists for Boeing aircraft. Boorman puts him in a flight simulator (I love this part, Gawande isn’t a pilot and it doesn’t sound like he has ever even flown in anything smaller than a 737) and throws an exploding cargo door at him on takeoff. By following the checklist, Gawande manages to abort the takeoff and land safely. (I’d bet anything he’s in flight school right now.)

Boorman instructs him on what makes a successful checklist. It has to be short. There have to be “pause points.” It should use both uppercase and lowercase text for ease of reading. And most importantly, it has to be tested.

So Gawande goes home and rewrites and rewrites and rewrites his OR checklist. And then he assembles an OR team in his conference room, puts a volunteer “patient” on the conference table, and tests it and tests it and tests it and then tests it some more. When it’s ready, he assembles eight hospitals from Tanzania to London to test it in their O.R.’s. And then he goes home and awaits results.

The final results showed that the rate of major complications for surgical patients in all eight hospitals fell by 36 percent after introduction of the checklist. Deaths fell 47 percent…Using the checklist had spared more than 150 people form harm–and 27 of them from death.

“Some skepticism persisted,” Gawande writes.

After all, 20 percent did not find [the checklist] easy to use, thought it took too long, and felt it had not improved the safety of care.

Then we asked the staff one more question. “If you were having an operation,” we asked, “would you want the checklist to be used?”

A full 93 percent said yes.

His checklist is now being adopted in O.R.s around the nation and around the world, albeit slowly and in some cases because surgeons have long been the gods of their O.R.s and are slow to give up power. You can blame ego for a lot wrong with the world. Highly recommended.

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Book Review Monday Chatter Atul Gawande The Checklist Manifesto