In The Checklist Manifesto, Atul Gawande, the author of Better and Complications and a general and endocrine surgeon at Brigham and Women’s Hospital, spends 193 pages talking about an idea that seems ridiculously simple: the checklist.

Whether the reader is an aviation pilot who has used hundreds of checklists during takeoff and landing (an example Gawande refers to frequently throughout the book), a college student who would be lost without Google Tasks, or a cubicle worker whose board is tacked with scribbled post-it notes, the book gets across its point. Using a checklist may seem silly, but as the reader can attest from the mundane experience of crossing items off a grocery list and as Gawande demonstrates through a World Health Organization study, the checklist can catch common mistakes and, in surgery, save lives.

In the introduction, Gawande asks why we fail at what we do. Either we do not know the answer, he surmises; or, we know the answer but fail to apply the knowledge correctly—a growing problem in our world today, with the explosion of information and lack of organization. Yet, in a field such as surgery, where the unexpected is the norm and where many deaths are avoidable, hospitals must find a way to help the entire team—the surgeon, the resident, the anesthesiologist, the scrub nurse—apply their knowledge in a situation of life and death. A simple checklist, Gawande argues, could make this difference.

Surgeons lead busy lives, often performing multiple procedures in a day on little sleep and sharing an operating room with a team they may not know. In this complex environment, it is easy to forget things that are important and it is easy to purposely forget things that are important but that a surgeon knows from years of experience don’t always matter. Unfortunately, these mistakes can be costly. Gawande describes how the recording of vital signs—blood pressure, pulse, temperature, and medication—didn’t become routine until the 1960s. Yet while nurses have put these checklists in place, making sure they know how their patients are doing, Gawande notes that doctors, with their year of training and “superspecialization” don’t think they need them. The checklists seem silly, even stupid.

In other areas of specialization; however, checklists have become the norm, a requirement for the profession. Gawande describes his visit to a construction site, where large sheets of paper contained detailed checklists for the tasks to be completed and the order in which they should be completed, the people who needed to talk and whether that communication had taken place. When he sits in the kitchen of renowned Boston chef Jody Adams, owner of Rialto, he sees a similar checklist in place—the recipe, with modifications and the chef’s notes—which every cook had to follow to prepare the food for each customer, all of whom had their own checklist to make sure their meal was delivered to their satisfaction.

As the reader goes along with Gawande, savoring Adams’s grilled clams and admiring the towering skyscraper built from a series of checks, we begin to wonder what Gawande has thought all along—can this simple checklist be used effectively in surgery?

Illustration by Sam Mendez

At a World Health Organization meeting in Geneva in 2007, Gawande recalls how Dr. John Snow traced a cholera outbreak in London in 1854 to a public well. By mapping where those who died had lived he found them surrounding a single water source, and, upon convincing the local government to remove the water pump handle, the disease ceased to spread. The contaminated water had been the culprit, and a simple intervention—removing the pump handle—had been the cure. Gawande realizes the intervention for surgery needs to similarly be “simple, measurable, [and] transmissible.” The checklist seemed ideal.

There are four main killers in surgery, Gawande explains: infection, bleeding, unsafe anesthesia, and the unexpected. Clearly, the last is the hardest to prepare for. A checklist can prevent the first three, but addressing the fourth is complex—and so the checklist included a step requiring the surgical team to introduce themselves and talk about the surgery, so that, as much as possible, they could anticipate the unexpected.  A WHO team condensed available checklists into one master checklist—nineteen steps, with three pause points: before giving the patient anesthesia, before making the first incision, and before wheeling the patient out of the operating room. Then the checklist was put to use in eight hospitals around the world to see if it worked.

Gawande admits he was nervous about the study. What if the checklist had no effect? Then the surgeons who scoffed at it would be right. So when his research fellows excitedly brought him the results, Gawande, instead of “dancing a jig on my desk”, poured over the papers for errors. But the results held—as Gawande writes, “the rates of major complications for surgical patients in all eight hospitals fell by 36% after introduction of the checklist. Deaths fell 47% percent…Infections fell by almost half…Overall, in this group of nearly 4,000 patients…Using the checklist had spared more than 150 people from harm—and 27 of them from death.”

And although Gawande triumphantly writes, “This thing was real,” the reaction of surgeons was still mixed. Yet, he tellingly reports that when staff members who used the checklist in surgery were asked “If you were having an operation, would you want the checklist to be used?…A full 93% said yes.”

Gawande acknowledges that the checklist has not caught on everywhere, and not only in medicine. “We don’t like checklists,” Gawande says. “They can be painstaking. They’re not much fun…It somehow feels beneath us to use a checklist, an embarrassment.”

But much like the checklists pilots use every day to ensure the plane is ready for takeoff, the checklists Gawande and his team designed for surgery “gets the dumb stuff out of the way, the routines your brain shouldn’t have to occupy itself with…and lets it rise above to focus on the hard stuff.”

In The Checklist Manifesto, Gawande presents a compelling argument, drawing the reader into his world as a surgeon and into the daily lives of contractors, pilots, and even chefs, all of whom have used the simple checklist and achieved awing results. Surgery, anyone will admit, is risky and dangerous. “No matter how routine an operation is, the patients never seem to be. But with the checklist in place, we have caught unrecognized drug allergies, equipment problems, confusion about medications…We’ve made better plans and have been better prepared for patients.” The checklists have made a difference. Perhaps their greatest asset is that they make us pause for a minute in our rushed lives and think about what we are actually doing. In that regard, all of us could use a checklist, whether or not we are about to perform a complex operation on a patient who has entrusted their life in our hands.




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