The Checklist Manifesto – Atul Gawande [Book Summary]

by Nick

An avalanche of new scientific knowledge and increasingly sophisticated methods has hit experts from a wide range of fields.

As a result, they begin to make mistakes, many of which could have been avoided. Surgeon Atul Gavande talks about how studying the principles of preventing fatal errors in aviation, construction and investment helped the World Health Organization find an effective solution for eliminating errors in operations.

WHO has compiled and recommended for use by surgeons a checklist that has saved the lives and health of many patients around the world.

The book is not a practical guide, but it analyzes the approach to checklists in a number of industries and presents several examples of checklists.

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Difficulty Increase

We consider ourselves the sovereign masters of our actions.

Why do we have so often failures and failures?

The cause of failure, according to the philosophers Samuel Horowitz and Alasdair MacIntyre, is universal error proneness.

Despite all the achievements of science, some of the tasks that we set ourselves are beyond human capabilities. In areas of increased complexity – such as the construction of skyscrapers, weather prediction, and complex surgical operations – even specialists of the highest level are forced to admit that the knowledge and skills accumulated over many years of training and practice do not always help.

“The volume and complexity of the knowledge gained prevents us from using their fruits correctly, safely and reliably. The knowledge that once gave us freedom has become our burden. ”

Failures have two reasons: ignorance or inability. Ignorance is rooted in the ignorance of the world by man. Inability is manifested in those cases when there is already the necessary knowledge, but people are not able to apply it correctly.

For example, in the field of medicine, science has recently given a huge amount of information about human health, and now the main problem is not their absence, but the inability to apply them consistently and on business.

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“Most of this world and the universe is and will be beyond our understanding and control.”

Despite the development of technology, in those areas that require large amounts of knowledge and interaction with complex systems, mistakes are made daily.

Let’s see what events form the basis of the news feed. Negligence of doctors and judicial errors, poorly written software, bankruptcy of financial organizations, incompetent actions of authorities during natural disasters.

“Mistakes of ignorance” are relatively easy to forgive, but when harm is done due to the non-use of existing knowledge, it causes a sharply negative reaction in society.

How to avoid mistakes?

The strategy for solving this problem “at first glance … may seem unnecessarily simple, even primitive.”

Use a checklist.


In the Austrian Alps, there was such a case.

A three-year-old girl fell under the ice of the pond, and her parents could only pull her ashore after half an hour. They began to give the child artificial respiration, and after eight minutes rescuers arrived at the scene.

But by this time, the girl’s body temperature had dropped to 18.9 ° C. The child, who did not show signs of life, was taken by helicopter to a local hospital.

The situation seemed hopeless, but the doctors tried to save the girl. Her chest was opened, she underwent bypass surgery and connected to a cardiopulmonary bypass system. Two days later, all organs, except the brain, began to function normally.

The child remained in a coma for more than a week.

Of course, the girl needed serious treatment, but by the age of five, she returned to normal life.

Surgeon, who led the heart surgery, linked the success of the medical team with the use of checklists implemented at his insistence.

They described the sequence of actions that must be performed in preparing the resuscitation team for the arrival of the patient.

“Experience is undoubtedly of great value, but in most cases, it is not enough.”

In October 1935, the US Air Force announced a competition among aircraft manufacturers to create a new generation long-range bomber. The best design was presented by Boeing. It seemed that flight tests for this aircraft would be a simple formality.

But a few minutes after a beautiful take-off, a huge four-engine plane lost speed and, crashing to the ground, exploded. Later it turned out that an experienced pilot who died in this crash forgot to “unlock control of rudders and heights”, as the new model was much more complicated than all previous ones.

Other testers did not insist on lengthening the training period. They decided to draw up checklists for the pilots to follow during take-off, flight and landing.

The introduction of the mandatory use of these pocket-sized cards saved Boeing from bankruptcy and helped turn the Model 299 prototype into a B-17 bomber, which later participated in the war against Germany.

With a total raid of almost three million kilometers, aircraft of this model did not suffer a single accident.

“Checklists form a kind of cognitive network into which all the errors of brain activity that are characteristic of each person and explained by lack of memory, attention and concentration fall into.”

Similar problems confront people of various professions – doctors, lawyers, architects, firefighters, and police officers. Their work is similar to that plane that has become too complicated for one person to fly.

In a difficult situation, professionals have to overcome two main difficulties: too much information falls on them that needs to be kept in mind, and they are distracted by many extraneous factors that prevent us from paying attention to every detail.

The End of the Universal Builder Era

From the Middle Ages almost until the middle of the twentieth century, all large structures were designed and built by universal master builders. They led the entire process, from design to completion.

To date, the diversity and complexity of all aspects of construction has significantly exceeded the capabilities of one person. Universal builders were divided into architects, engineers and contractors.

Each of these categories distinguished its own narrow specialties. These people have no right to make a mistake. Realizing this, they developed a way to coordinate collaboration — a system of checklists drawn up for each stage of the construction process.

“We need to force people not to make even stupid mistakes while leaving room for maneuver so that the specialist can show his skill and prudence, as well as the ability to cope with unforeseen circumstances that arise constantly.”

How is this done in practice? No one gives permission to proceed to the next stage (even the most insignificant) of construction, without checking whether all the work related to the previous ones has been completed.

Contractors post large prints of checklists all over the wall so that they can follow with their eyes the progress of each operation. Of course, special software for project management and special communication systems are also used.

A study conducted in 2003 showed that in the United States there is an average of 20 serious construction errors per year – this is a negligible fraction of the total number of facilities being built. Conclusion: checklists work.

What Situations Need a Checklist?

The builders’ strategy has an important condition: the right to make decisions in case of force majeure circumstances is vested in practitioners directly conducting work.

Most authorities, on the contrary, do not dare to delegate extended powers to subordinates on the ground, relying more on checklists drawn up for them. But checklists work better in situations of every day, regularly repeating tasks than in the case of a large-scale crisis.

This was firsthand demonstrated by Hurricane Katrina. The officials of the Federal Emergency Management Agency were guided by the usual command-administrative approach, as if not noticing that the situation was becoming increasingly threatening. And they, of course, should delegate the right to make decisions on the spot.

“Nobody set out to make people just check the boxes [of the checklist]. The main thing was to create a culture of teamwork and strengthen discipline. ”

The retail giant Walmart went the right way. Immediately after the hurricane, the company gave managers of stores located in the disaster zone the full right to act as they deem necessary in order to provide assistance to the victims.

Some simply handed out all stocks of goods to those who urgently needed them. Others gave out food, tools and sleeping bags to those who applied for help, writing them down in a conditional loan – simply on sheets of paper.

And top management focused on providing communications.

The around-the-clock call center was opened for company employees. As it turned out, for actions in complex, unforeseen circumstances, when no one knows and cannot know everything that is needed, a mechanism is required to ensure the fulfillment of two different, sometimes contradictory tasks.

Such a mechanism should:

1) to strictly guarantee that at a critical moment some small but extremely important detail will not be missed;

2) provide communication between people working in extreme situations.

By order of the World Health Organization

In 2006, representatives of the World Health Organization (WHO) asked the author of the book, Atul Gavande, to organize a group to study the situation with complications after surgery and make recommendations.

According to WHO, due to postoperative complications in the world at that time, at least one million people died every year, and another seven million remained disabled. WHO has set a goal: to achieve a “measurable, inexpensive and significant reduction in the total number of complications”.

The working group considered a number of proposals (additional training, material incentives, development of international standards), but none came up. It was decided to analyze the existing practice of using checklists in medicine.

“We are not made for discipline. We like novelty and enthusiasm, not meticulous attention to detail. We just have to develop discipline in ourselves. ”

In one case, protesters handed out antibacterial soap in slums of the city of Karachi in Pakistan. At the same time, enlightenment work was conducted with the population. In the form of a checklist, six rules were set forth that governed the daily use of soap for personal hygiene, in cooking, and for childcare.

During the year during which the experiment was conducted, the number of cases of diarrhea in local children decreased by 52%, the incidence of pneumonia – by 48%, and skin diseases – by 35%.

“Checklists should not be unchanged, otherwise over time they will interfere more than help. Even the simplest of them must be constantly reviewed and improved. ”

Another example was the experience of a children’s hospital in Columbus (Ohio).

The leadership of this institution found that when carrying out operations to remove the appendix, more than a third of patients did not receive the prescribed antibiotics at the right time.

Then the head of the surgical department, who was a pilot in his youth, decided to apply methods from aviation in medicine. He compiled a checklist called “Takeoff I allow.”

They began to cover surgical instruments with a special metal pyramid with the same inscription. Only after the nurse was convinced of the implementation of all preoperative actions, she removed the pyramid and the surgeon could take up the scalpel.

It was the nurses who were given the authority to suspend the start of the operation if at least one of the items on the checklist turned out to be unfulfilled, – So in practice the principle of redistribution of powers was implemented.

After three months, already 89% of patients received the prescribed antibiotics on time, and after 10 months – 100%. Checklists have also been used at surgical departments at the Universities of Toronto and Johns Hopkins and at the Kaiser Consortium hospitals.

Checklists requiring members of operational teams to get to know each other, discuss upcoming actions and confirm the fulfillment of all items significantly increased the level of team cohesion and improved the results of operations.

Checklists have also been used at surgical departments at the Universities of Toronto and Johns Hopkins and at the Kaiser Consortium hospitals.

Checklists requiring members of operational teams to get to know each other, discuss upcoming actions and confirm the fulfillment of all items significantly increased the level of team cohesion and improved the results of operations.

Checklists have also been used at surgical departments at the Universities of Toronto and Johns Hopkins and at the Kaiser Consortium hospitals.

Checklists requiring members of operational teams to get to know each other, discuss upcoming actions and confirm the fulfillment of all items significantly increased the level of team cohesion and improved the results of operations.

What a Checklist Should Be Like

If the checklist is poorly compiled, it is a danger.

This is warned by an experienced pilot, Daniel Boorman, who for 20 years compiled checklists and participated in the creation of dashboards for Boeing aircraft.

If the checklist is written too “vaguely and inaccurately”, it is too long, it is difficult to put into practice in conditions of time pressure, then there is no use to it.

On the contrary, good checklists are “specific and easy to use even in difficult situations.”

When compiling a checklist, follow these rules:

  • 1) Be sure to include “killer points” – actions whose non-fulfillment poses a serious danger;
  • 2) Place the text on one sheet;
  • 3) Use not a bureaucratic language, but the professional vocabulary of your industry;
  • 4) Sans serif fonts are preferred;
  • 5) Words can be written as lowercase, both in capital letters;
  • 6) Test the compiled checklist in real conditions, and then make changes.

“After all, a checklist is just a guide. If it does not help, it means that mistakes were made in its preparation. But if the checklist can help, then we should not miss this opportunity. ”

Boeing uses two types of checklists, depending on the situation. When the crew needs to act quickly and from memory, “DO-CONFIRM” lists are used – they are periodically checked with them.

In other cases, actions are phased in according to the list, as if by notes – such check-lists are called “READ-DO”. But no matter how wonderful the checklist is, its mere presence is not enough to start working with it.

Pilots are taught that a person’s memory and his ability to logically evaluate a situation are imperfect and that a person is prone to errors. Good pilots – unlike many surgeons – recognize the limitations of their abilities.

Therefore, in the event of a dangerous situation, pilots readily turn to checklists.

A Surgical Checklist Test

After studying the experience of the pilots, the working group of surgeons at WHO removed in the first version of their checklist those items that took too much time.

The final surgical checklist, approved by WHO, contains 19 control checks, or points: seven of them relate to anesthesia, seven to preoperative preparation, and the remaining five are performed after surgery, but still in the operating room.

It is designed for two minutes.

The effectiveness of the checklist was tested in eight hospitals in different countries, both with high income (USA, Canada, England, New Zealand) and low (Philippines, Jordan, India, Tanzania).

In 2008, staff training was conducted at these medical facilities. Just three months after the start of the experiment, the number of postoperative complications decreased by 36%, mortality decreased by 47%, and infections are almost doubled. A survey of 250 members of operating teams showed that 80% of them find the checklist easy to use, and 78% witnessed how this procedure helped prevent a medical error.

By the end of 2009, 12 countries had committed using checklists in hospitals.

In Other Industries

Checklists open up new possibilities in virtually any field and in any enterprise. From an interview with three successful investors, we learn that they attribute their success to checklists based on their own experience or information on the activities of colleagues.

Warren Buffett also invariably uses his own mental checklist. The introduction of checklists in other areas was not yet methodological in nature.

The mistakes of teachers, lawyers, government officials, representatives of the financial and other industries were hardly systematized in any way. Think about your work yourself.

If the same mistakes are repeated regularly, then it is time to apply the checklist manifesto.


  • Science has given professionals opportunities that exceed the ability of people to use them effectively.
  • In many areas of activity, what a professional needs to do has become like a plane that is “too complex for one person to fly on”.
  • Since the mid-1930s, aviators have been convinced that flights require consistent application of checklists covering even the most routine operations.
  • The increasing complexity of the construction industry has led architects, engineers, and contractors to develop written checklist systems and communication standards.
  • In an emergency, management should ensure that some small but important detail is not missed, and ensure that there is communication between employees on the spot.
  • Stress due to the need to urgently make decisions leads to medical errors.
  • In 2009, the World Health Organization developed a checklist that prevented a huge number of postoperative complications.
  • The checklist should include “killer items”, fit on one sheet, be written in the language of the industry. Before implementation, it should be tested in practice.
  • Checklists can be of two types: those with which they are periodically checked, acting from memory, and those for which actions are performed in stages, such as by notes.
  • Professionals must acknowledge that it is human nature to make mistakes and begin to use specially designed checklists.

Why You Should Read “The Checklist Manifesto”

  • To learn how to develop checklists for better performance and productivity
  • To perform tasks of increased complexity
  • To deal with the burden of responsibility for the lives of other people

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