The Checklist Manifesto

by Atul Gawande


Much of the work that we do is related to thinking differently and so recommending a book on something as mundane and resytrictive as using checklists may seem like a strange approach. However Atul Gawande is recommending the use of checklists in complicated and complex environments in order to free our minds from having to concentrate on the minutiae of what we are trying to do.

This book basically tracks the authors trials of checklist methods used in the aviation and construction industries in surgical situations. Surgical theatres are often dominated by individuals with strong egos and trying to get them to adopt checklists in what they do was a supreme challenge because it was almost insulting to those involved – it implied they could not do their job. The most illuminating comment on this comes from the author himself towards the end of the book where he says on his attitude before the trials began (p186):

"if you strapped me down and threatened to take out my appendix without anaesthesia unless I told you the truth – did I think the checklist would make much of a difference in my cases? No. In my cases? Please"

This is from someone who was developing and advocating a trial of check lists in surgeries around the world on behalf of the WHO. He goes on to say:

To my chagrin, however, I have yet to get through a week in surgery without the checklist's leading us to catch something we have missed".

He then goes on to describe several simple and one more terrifying example of these "saves".

The key results of the WHO trial were that across 8 different hospitals in different countries, including the developing world and a major US and a major British hospital the use of the trial checklist reduced major complications by 36% and deaths by 47%. Similar sorts of impressive numbers were realised for a checklist for the insertion of central lines in intensive care patients where the levels of infections fell dramatically. It is frightening to read the number of simple errors in this relatively straightforward procedure that were picked up by the use of a check list.

The author states that he is still having trouble getting people to adopt the check list approach and says that if a new machine or antibiotic achieved the results that have been achieved in these trials the medical profession would be tripping over themselves to adopt them. This is a real problem in the system of medicine where the field has become more and more complicated but the myth of the "hero surgeon" prevails.

As well as picking up simple errors the author believes that a lot of the improvement has come from engendering a sense of teamwork and equality, especially where nurses and others are given the power to run the checklist, and prevent action until it is complete. Many teams for surgery in modern hospitals might only come together for one operation and the author believes the discipline of having a conversation around the checklist has improved equality, teamwork and communication in the surgical operating theatre.

The author is not advocating that checklists are the be all and end all, just that they can be used in certain situations to significantly reduce errors, deal with risk and free our minds from the detail so we can concentrate on where we should be concentrating. If I have one criticism of the book then it is that for a relatively short book (197 pages) there are too many long descriptions of the detail around some of his experiences outside of the operating theatre. I do not think that the details adds anything to the argument and it is almost as if the publishers believed a 120 page book would not sell.

Other than that criticism I would strongly recommend reading this book and thinking about where a check list might work in your organisation. The book is easy to read and presents a compelling argument with real examples and data to back them up but is not advocating a one solution fits all approach. You just might be surprised.