Atul Gawande, The Checklist Manifesto

A short but powerful read on the importance of checklists in areas of life-threatening activity under complexity. Atul Gawande’s book contains several color stories from the world of aviation, mostly pointing out near-misses that were never detected due to the use of checklists. The author’s focus, however, is on their use in the operation theater and, by extension, to any other area of complex professional activity.

The problem today, he argues, is that we no longer have a “master builder” who oversees and understands all the applications of the technology they command. Instead, we have ever increasing complexity that demands that experts communicate with one another. As this could be fraught with the usual human frailties (refusal, denial, silence, etc), he proposes two kinds of checklists, as currently in use in airplane cockpits:

  1. A Do-Confirm checklist: after a critical incident, research shows that well-trained and experienced professionals will complete steps in a process automatically. This kind of checklist covers those points – and only those points – that, if forgotten, could cause a crash or kill a patient. This so-called pause-point requires professionals to communicate and confirm what has been done as the entire team (airplane cockpit, operation theater) listens in.
  2. A Read-Do checklist: operators check off tasks in order much like a recipe – the kind of checklists we are familiar with from movies.

An interesting point: Checklists are NOT comprehensive, NOT a step-by-step recipe. Adminstrative details that are either non-critical or likely to be completed anyway (pilots ALWAYS contact air control in case of emergency) are NOT included. Researchers argue that it is more important to stay alive first; if you have forgotten a non-life-threatening step, you can do it later. The critical features of such checklists are also a checklist:

  • Brevity – keep it between five to nine items, around 60-90 seconds in duration. Any longer and people will forget, be overwhelmed, or ignore it when a critical incident becomes an emergency.
  • Simplicity – simple sentence syntax, using words of the trade and correction orthography. It should fit on one page, be large enough to read in poor lighting without glasses, and use a sans-serif font.
  • Robustness – the checklist should be trialed and revised well before its actual implementation. First drafts always fail and institutions have their own way of doing things.

Read this book for inspiration and to begin thinking about where checklists can be instituted at your place of work.