[2021-12-12] The Checklist Manifesto
In 1935, the U.S. Army Air Corps held a competition to find the next generation of its long-range bomber. Boeing Corporation's entry—which could carry five times as many bombs as the army had requested—was the clear favourite. But moments after takeoff, Boeing's Model 299 crashed in a fiery explosion, killing two of its five crew members.
An investigation revealed that there was nothing wrong with the mechanics of the plane; instead, investigators blamed pilot error for the crash. The plane was simply too complex, leading journalists to say that it was "too much airplane for one man to fly."
The U.S. Army Air Corps bought only a few of the planes, rather than the 65 it had anticipated purchasing before the competition. To ensure the plane could be flown, a group of test pilots did what would become routine in aviation: they created a pilot's checklist.
From the airplane to the operating room
While checklists have been used extensively in aviation, they haven't taken off in other fields. That was the conclusion of Dr. Atul Gawande, a surgeon and author of The Checklist Manifesto: How to Get Things Right. In this 2009 book, Gawande notes:
We don't study routine failures in teaching, in law, in government programs, in the financial industry, or elsewhere. We don't look for the patterns of our recurrent mistakes or devise and refine potential solutions for them.
Even in his own field of surgery, Gawande witnessed a reluctance to use checklists despite the obvious benefits of doing so.
In 2006, the World Health Organization contacted Gawande to organize a group of people to develop a global program to reduce avoidable deaths and harm from surgery. The number of surgeries worldwide was increasing, and a significant portion of the care was so unsafe as to be considered a public danger. Gawande explains the source of the danger:
Surgery has, essentially, four big killers wherever it is done in the world: infection, bleeding, unsafe anesthesia, and what can only be called the unexpected. For the first three, science and experience have given us some straightforward and valuable preventive measures we think we consistently follow but don't. These misses are simple failures—perfect for a classic checklist.
With his colleagues, Gawande developed the safe surgery checklist, testing it in eight hospitals around the world. The result was a 36% decrease in the rate of major complications for surgical patients, a 47% decrease in deaths, and an almost 50% decrease in infections.
Gawande acknowledges that checklists worked well for highly repeated processes, such as putting in a central line in a patient to administer fluids or medication, but not so well for the many thousands of complications that may occur, especially in surgery. For such complications, a different approach was needed. Gawande writes:
But the fourth killer—the unexpected—is an entirely different kind of failure, one that stems from the fundamentally complex risks entailed by opening up a person's body and trying to tinker with it. Independently, each of the researchers seemed to have realized that no one checklist could anticipate all the pitfalls a team must guard against. So they had determined that the most promising thing to do was just to have people stop and talk through the case together—to be ready as a team to identify and address each patient's unique, potentially critical dangers.
Gawande, and other researchers, found that people who don't know each other's names don't communicate as well, work together as effectively, or speak up as much as people who do. The solution—for surgery at least—was to have teams take a few minutes before the operation to introduce themselves and their role and to share any concerns they had about the procedure. Gawande notes:
The investigators at Johns Hopkins and elsewhere had also observed that when nurses were given a chance to say their names and mention concerns at the beginning of a case, they were more likely to note problems and offer solutions. The researchers called it an "activation phenomenon." Giving people a chance to say something at the start seemed to activate their sense of participation and responsibility and their willingness to speak up.
Both for my recent surgery in November and my hysterectomy in 2020, the medical team discussed the operation they were about to perform on me. This ritual, which began before the anesthesia kicked in, appeared to be exactly what Gawande describes in his book. And I imagine that all team members knew each other by name given that they introduced themselves to me by name (or were introduced to me by other team members) before the surgery began.
Checklists for reducing mistakes
Gawande asserts that checklists could be helpful in any profession, not just aviation and surgery where failures can have life-and-death consequences. He writes,
We have an opportunity before us, not just in medicine but in virtually any endeavor. Even the most expert among us can gain from searching out the patterns of mistakes and failures and putting a few checks in place.
He adds:
When we look closely, we recognize the same balls being dropped over and over, even by those of great ability and determination. We know the patterns. We see the costs. It's time to try something else.
But he also recognizes that many professionals resist checklists, thinking they're better than a checklist or that such a tool would hinder, not help, their performance.
It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us—those we aspire to be—handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists.
However, under pressure, checklists can be crucial to performance. Gawande cites the example from 2009 of US Airways Flight 1549, which hit a flock of Canada geese minutes after takeoff, losing both engines. The pilots made a spectacular landing on the Hudson River in New York City and were hailed as heroes for saving all 155 people on board.
Perhaps lost in the reporting was that they had used a checklist, one that had resulted from a previously encountered problem much like the one these pilots faced.
What makes a good checklist?
For anyone looking to develop a checklist, Gawande distinguishes between bad checklists and good checklists:
Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat the people using the tools as dumb and try to spell out every step. They turn people's brains off rather than turn them on.
Good checklists are the opposite. They are:
- Short – between 5 and 9 items, focusing on what Gawande called "the killer items" that is "the steps that are most dangerous to skip and sometimes overlooked nonetheless."
- Simple and precise – using "the familiar language of the profession."
- Able to fit on one page – "They are not comprehensive how-to guides.... They are quick and simple tools aimed to buttress the skills of expert professionals."
- Free of clutter – no superfluous use of colour, fonts and graphics.
- Easy to read – using both upper and lower case, because text in all caps is more challenging to read.
Gawande adds that checklists must be tested in the real world until, through study and changes, they work consistently.
I'm happy that the kinds of solutions Gawande sets out in his book appear to be at work in The Ottawa Hospital, not just in surgery but in hospital care and cancer treatment as well. For instance, every time I received a medicine or had my vitals checked, the nurse would scan a QR code on my admissions bracelet to register this information.
I found The Checklist Manifesto to be an interesting read—worth a look by anyone involved in repeated tasks that are prone to errors.
