"Stupid Little Checklists"

Did you ever go to the market only to find you left your shopping list at home? Who hasn’t? Who hasn’t made far more serious mistakes? Doctors make them all the time, airline pilots do on occasion, construction engineers are known to make them too.

Dr. Atul Gawande’s latest book, The Checklist Manifesto: How to Get Things Right, is a study of mistakes, about making and preventing them and how to do so quickly and effectively, at least how to make a start in that direction. Gawande is a surgeon, a staff writer for the New Yorker, a professor at Harvard, and a MacArthur fellow. It is a mistake not to listen to him.

Early in the book he writes, “…the volume and complexity of what we know has exceeded our individual ability deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.”

Consider the enormously complex situation an airline pilot faces as he sits in the cockpit getting reading to fly a massive 358,000 lb (that’s empty) Boeing 747 crammed with 545 passengers several thousand miles across the sea. At least a thousand things could go wrong causing the death of the passengers to say nothing of himself and his 33-member crew. How does he avoid making a potentially horrible mistake—a single one could be fatal--in a situation where countless things that could go wrong?

What he does is to start going over, one by one, a set of really simple checklists. There are the checklists he goes over as he inspects the outside of the plane, and those that he reviews before turning on the engines, and another set before pulling away from the gate, plus those before taxiing out to the runway, etc.

He also has a sizable notebook consisting of the “non-normal” checklists “covering every conceivable emergency situation a pilot might run into: smoke in the cockpit, different warning lights turning on, a dead radio, a copilot becoming disabled, and engine failure, to name just a few.” Gawande dramatically describes instances when a careful review of one of these checklists avoided a crash and a few when they weren’t looked at carefully that ended in a tragedy.

Gawande admits doctors don’t much like those “stupid little checklists,” that they aren’t much fun, and that physicians are often reluctant to employ them, largely because they raise doubts about their competence. Against this reluctance, he marshals one study after another to demonstrate how effective checklists are in reducing the alarming number of medical errors.

In one study the introduction of a checklist reduced infections when an intravenous line is inserted into patents in intensive care units (I.C.U.) to zero from its normal rate of 11 percent. Two years after the checklist was introduced it was estimated that it had prevented 43 infections, avoid 8 I.C.U deaths, and saved the hospital in which it was studied approximately $2 million.

Another study for the World Health Organization examined the effects of introducing checklists in surgical care at eight hospitals in both developed and undeveloped countries. “The rate of major complications for surgical patients in all eight hospitals fell by 36 percent after the introduction of the checklist. Deaths fell 47 percent. …Overall in this group of nearly 4,000 patients, 435 would have been expected to develop serious complications based on our earlier observation data. But instead just 277 did. Using the checklist had spared more than 150 people from harm—and 27 of them from death.”

The checklist may seem like a minor, relatively innocuous tool to employ in order to avoid making mistakes. The evidence that Gawande assembles from medical, construction, and aviation situations suggests otherwise. It is another mistake not to take these findings seriously.

Errors will continue to be made, accidents will occur, mental lapses are inevitable, but the use of a checklist will help overcome some of them. They are a start and only a start in confronting the fallibility of the human judgment in the face of the increasing complexity of modern life.