In the 21st century, we can do extraordinary things: We can predict dangerous storms, explore distant planets, and save people from life-threatening conditions and injuries. Yet highly trained, experienced, and capable people regularly make avoidable mistakes.
In The Checklist Manifesto, Boston surgeon Atul Gawande contends the reason is that knowledge and complexity in many fields have exceeded the capacity of any individual to get everything right. Under pressure, we make simple mistakes and overlook the obvious. Drawing lessons from spectacular successes and failures in recent years, he argues that the solution is a checklist. The book builds the case for checklists and issues a plea for adopting this backstop to human fallibility.
The Checklist Manifesto
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The Checklist Manifesto by Atul Gawande .
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:
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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.
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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.
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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.
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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.
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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:
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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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