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The Checklist Manifesto

Beyond the usual job of organizing the material, at various places, I have expanded/amended the argument. For instance, I provide a psychological account of why some surgical checklists have worked in some cases (social pressure), and what are the potential concerns around introducing checklists, etc.

Portions of the book suggest that this is less about checklists and about engineering processes that reduce errors. Any process can be called a checklist---you do X followed by Y followed by Z---but that is stretching it.

  • Three reasons for why we fail according to Samuel Gorovitz and Alasdair MacIntyre

    • necessary fallibility --- stuff is beyond humanity's comprehension for now.

    • of the stuff we know, we fail because of:

      • ignorance: practitioners don't know
      • ineptitude: practitioners don't apply what they know correctly
        • Reasons (not via G and M):
          1. The first is the fallibility of human memory and attention, especially when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events.

          2. People may think that steps don't matter---overconfidence, laziness, etc. --- Line out minimum necessary steps

  • Problem Statement: How do you make sure that people know and are following the process correctly?

  • To improve outcomes---study routine failures and how you would amend the process to improve outcomes.

  • Solutions:

    • Increase in training requirements

      • downside: the pace of growth of knowledge > sustainable increase in training time.
    • Specialization: "There are pediatric anesthesiologists, cardiac anesthesiologists, obstetric anesthesiologists, neurosurgical anesthesiologists ..."

    • Punish failure and give rewards for doing the right thing:

      • pay for performance benefit ~ 2--4% for surgeons in one trial.
    • Checklists for ineptitude reasons 1 and 2

    • Automating tasks or reporting of failures of adhering to guidelines

    • Forcing functions: "A behavior-shaping constraint, also sometimes referred to as a forcing function or poka-yoke, is a technique used in error-tolerant design to prevent the user from making common errors or mistakes. One example is the reverse lockout on the transmission of a moving automobile." Microwave: open the door to power off.

      • Automation
      • Mandatory Communication.
    • When working with a rotating set of people

      • Introductions help (people who know each other's names work better together)
      • Ask for concerns around key areas

Volume of Surgery And Complication Rate, Other Issues in Medicine

  • Americans today undergo an average of seven operations in their lifetime, with surgeons performing more than fifty million operations annually—the amount of harm remains substantial. We continue to have upwards of 150,000 deaths following surgery every year—more than three times the number of road traffic fatalities.

  • By 2004, surgeons were performing some 230 million major operations annually—one for every twenty-five human beings on the planet ---

    • "Worldwide, at least seven million people a year are left disabled and at least one million dead"
    • a bunch is avoidable --- this one from evidence from Gawande's paper.
  • Major reasons for complications from surgery =

    • infection, bleeding, unsafe anesthesia, and what can only be called the unexpected.
  • Time from discovery to adoption:

    • "On average, the study reported, it took doctors seventeen years to adopt the new treatments for at least half of American patients."


  • Every day in the US, "some ninety thousand people are admitted to intensive care." "Over a year, an estimated five million Americans will be, and over a normal lifetime nearly all of us will come to know the glassed bay of an ICU from"

  • "The average stay of an ICU patient is four days, and the survival rate is 86 percent."

  • Error Rate:

    • From Israel: "engineers observed patient care in ICUs for twenty-four-hour stretches. They found that the average patient required 178 individual actions per day, ranging from administering a drug to suctioning the lungs, and every one of them posed risks. Remarkably, the nurses and doctors were observed to make an error in just 1 percent of these actions—but that still amounted to an average of two errors a day with every patient"

    • Half of the 150k surgical deaths and 'and major complications' avoidable ("research consistently showed")

  • Infection Rates: (Most avoidable if you note results from Pronovost)

    • ICUs put five million lines into patients each year, and national statistics show that after ten days 4 percent of those lines become infected.

    • Line infections occur in eighty thousand people a year in the United States and are fatal between 5 and 28 percent of the time, depending on how sick one is at the start. Those who survive, stay an extra seven days in the ICU.

    • After ten days with a urinary catheter, 4 percent of American ICU patients develop a bladder infection.

    • ten days on a ventilator, 6 percent develop bacterial pneumonia, resulting in death 40 to 45 percent of the time.

Construction --- Scale and Error Rate

  • "In the United States, we have nearly five million commercial buildings, almost one hundred million low-rise homes, and eight million or so high-rise residences. We add somewhere around seventy thousand new commercial buildings and one million new homes each year."

  • Building failure = partial or full collapse of the structure.

  • "Ohio State University study, the United States experiences an average of just twenty serious “building failures” per year. That’s an annual avoidable failure rate of less than 0.00002 percent.


  • History = Model 299 (B-17) considered too complicated but w/ checklist ---works.

  • Proof of Efficacy:

    • Peter Pronovost/JHU Hospital

      • "Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a mask, hat, sterile gown, and gloves, and (5) put a sterile dressing over the insertion site once the line is in."
      • the ten-day line-infection rate went from 11 percent to zero.
      • Propping up head and antacids: "The proportion of patients not receiving the recommended care dropped from 70 percent to 4 percent, the occurrence of pneumonia fell by a quarter, and twenty-one fewer patients died than in the previous year."

      • Michigan: "In the first month, the executives discovered that chlorhexidine soap, shown to reduce line infections, was available in less than a third of the ICUs."

      "Within the first three months of the project, the central line infection rate in Michigan’s ICUs decreased by 66 percent."

      "In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated $175 million in costs and more than fifteen hundred lives."

    • Gawande

      • "Of the close to four thousand adult surgical patients we followed, more than four hundred developed major complications resulting from surgery. 56 dead. Half of the complications involved infections." complication rate from 6 to 21%.
      • Six safety steps tracked: hospitals missed at least once in 2/3rd of the patients
      • "The final results showed that 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 ... Infections fell by almost half." 435 to 277
    • Ad hoc from Pabrai etc.

      • Enron --- discover from company’s mandatory stock disclosures that senior leadership had sold stocks.
  • Construction (where people must work together):

    • Schedule of tasks: A list of all tasks that need to be completed in sequence. This list is filled out by all 16 trades, overseen by structural engineers, and sent to each for approval.

    • Schedule of sign-offs: To make sure stuff has been done correctly. 'submittal schedule': experts need to talk to each other about X by Y date. for instance, by Y date: diff. people have to review the condition of the elevator cars and talk about it. talk to fire-proofers by day X, talk to elevator engineers by Y, etc.

    • Semi-Automation: 'clash detective' which showed where specifications conflicted with each other or building regulations --- structural beam where lighting is supposed to go. --- to resolve this, sends emails to relevant people who need to meet together to resolve.

    • Anyone can flag an issue. And it will send out an email to relevant people. And the person can track progress. Each party given 3 days to sign off on.

  • Types of "Checklists"

    • Basic Measurements as a checklist?

      • "Comprised of four physiological data points—body temperature, pulse, blood pressure, and respiratory rate" (these days pain is the 5th one)
    • Mandatory communication + sign-offs from various parties.

      • at various 'pause points' around specific checks --- is this done, this done, this done, ...
    • Recipe: steps + details about how to execute those steps. (though people can propose changes)

    • Do-confirm (do stuff from memory and then confirm) or Read-do checklist (read and then do)

  • How to build checklists and properties of good checklists (most via Boorman):

    • Define a 'pause point' where the checklist is supposed to be used
    • What kind of checklist --- do-confirm or read-do etc.
    • 5--9 items
    • Wording should be simple and exact
    • Free of clutter, sans-serif, etc.
    • Must be tested in real world --- or simulations of it
    • Don't list stuff people don't miss
    • Give the responsibility of checklist to #2 or someone else. Not the person in charge.

Concern w/ Some Checklist Implementations And Some Solutions

  • Incentives for following checklists may be weak. How do you get people to follow?

    • social pressure --- checklist publicly marked as in a surgery
    • communicate clearly the issues and evidence on the efficacy of checklists
    • get people to own the checklists---put their name, get their ideas on it --- induce accountability
    • checks of whether the stuff was followed and incentives and rewards based on that.
  • People may stop using their brain and just follow the checklist

    • how to put in checklists that clarify that brain cells are imp. and incentivize that.
  • Train people to use checklists


  • Soap: Consequence of distributing soap in poor areas: "Families in the test neighborhoods received an average of 3.3 bars of soap per week for one year. During this period, the incidence of diarrhea among children in these neighborhoods fell 52 percent compared to that in the control group, ... incidence of pneumonia fell 48 percent. And the incidence of impetigo, a bacterial skin infection, fell 35 percent."

  • Complexity of Medicine

    • "Clinicians now have at their disposal some six thousand drugs and four thousand medical and surgical procedures, each with different requirements, risks, and considerations."

    • WHO list of total number of diseases, syndromes, types of injury: "more than thirteen thousand"

    • Harvard Vanguard:

      • "Over the course of a year of office practice—which, by definition, excludes the patients seen in the hospital—physicians each evaluated an average of 250 different primary diseases and conditions. Their patients had more than nine hundred other active medical problems that had to be taken into account."

      • doctors each prescribed some three hundred medications, ordered more than a hundred different types of laboratory tests, and performed an average of forty different kinds of office procedures—from vaccinations to setting fractures.

    • "a third of patients have at least ten specialist physicians actively involved in their care by their last year of life" + PAs + Nurses etc.

  • Complexity of Construction

    • on any given day he has between two and five hundred workers on-site, including people from any of sixty subcontractors.
    • 16 different trades
  • India: "The hospital had seven fully trained anesthetists, for instance, but they had to perform twenty thousand operations a year" NZ had 92 to manage the same number.

  • PH Brain Drain "Manila... it turned out there was only one nurse for every four operations."

  • Restate professionalism as skill + discipline (to follow the steps) + selflessness

Cool Examples

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