A Simple Little Checklist

The Louvre Museum in Paris, the most visited museum in the world, with a collection of paintings ranging across every school, the home of the Mona Lisa, the Venus de Milo, the
Winged Victory, etc. etc, is currently exhibiting a collection of prints and drawings of lists. At the invitation of the museum, the exhibition was created by Umberto Eco who chose to work on the theme he described as The Infinity of Lists. Lists? Where is the art in Lists? My grocery list is scarcely readable. In an interview in Spiegel Online, Eco answers:

“The List is the origin of culture. It’s part of the history of art and literature. What does culture want? To make infinity comprehensible. It also wants to create order…How does one attempt to grasp the incomprehensible? Through lists, through catalogues, through collections in museums and through encyclopedias and dictionaries. There is an allure to enumerating how many women Don Giovanni slept with: It was 2,063, at least according to Mozart’s librettist, Lorenzo da Ponte. We also have completely practical lists—the shopping list, the will, the menu—that are also cultural achievements in their own right.”

Eco, whose works include Foucault’s Pendulum and The Naming of the Rose, says his novels are full of lists. Asked why he is so interested in the subject, Eco replied, “I can’t really say. I like lists for the same reason other people like football, or pedophilia. People have their preferences.”

Eco isn’t the only one who thinks lists are important. So does Atul Gawande who wrote in the Dec 10th, 2007 New Yorker about the critical importance of the checklist in intensive care. While the use of a checklist may seem obvious to most, it isn’t commonly employed in the enormously complex intensive care units. Gawande claims that most physicians don’t believe that “something as simple as a checklist could be of much help in medical care.”

Yet, one study of patient care in I.C.U.s during a twenty four hour period observed that the average patient required 178 actions per day, ranging from drug administration to suctioning the lungs and every one posed risks and the possibility of error. No one can expect a physician under such demanding conditions to be able to remember and implement so many separate actions.

Another study identified the steps to take in order to avoid a single problem in I.C.Us., line infections. When a rather lengthy checklist of each one of the steps was created, it was observed that at least one was omitted in more than a third of the patients. And when, in another study, physicians and nurses were required to check off each step in a checklist, Gawande reports “the infection rate in Michigan’s I.C.U.s decreased by sixty percent…Michigan’s infection rates fell so low that its average I.C.U. outperformed ninety percent of I.C.U.s nationwide…[saving] more than fifteen hundred lives. The successes have been sustained for almost four years—all because of a stupid little checklist.”

A checklist may have also played a crucial role in the survival of all the passengers on Flight 1579 which landed safely in the Hudson River a few months ago. It now appears that it wasn’t only Captain Sullenberger’s piloting skills, to say nothing of a good deal of luck, that avoided a catastrophic crash in the Hudson, but also the fact that Sullenberger and his crew carefully went through a checklist before they took off of each of the steps to take if the engines failed in flight. It was only a few moments later that they were required to recall and carry out each one of the actions they had reviewed prior to take off.

As Eco notes in his interview, “At first, we think that a list is primitive and typical of very early cultures, which had no exact concept of the universe and were therefore limited to listing the characteristics they could name. But, in cultural history, the list has prevailed over and over again. It is by no means merely an expression of primitive cultures.”