The Checklist Manifesto by Atul Gawande

Gawande, Atul. The Checklist Manifesto: How to Get Things Right. New York: Picador, 2009.

Many of the things in our modern world are very complex. Little things done are not done, especially by the experts who undertake some of the most complex tasks, can have significant results. Surgeon Atul Gawande suggests a solution for managing this complexity and making sure that those important, little things aren’t overlooked. His solution is the checklist.

The thread through his book, The Checklist Manifesto, is the development by the World Health Organization (WHO) of a surgical checklist. WHO wanted to reduce surgical complications, especially in the third world. The team they put together, including Dr. Gawande, eventually settled on a checklist.

It was met with much skepticism, even on the part of those who developed it. The results changed minds. Use of the checklist cut serious complications from surgery almost in half. Dr. Gawande recounts his own experiences using the checklist and how it helped him prevent and solve surgical problems.

The checklist isn’t purely a matter for medicine. A very successful user of checklists is the aviation industry.

Aviators were once like surgeons, seen as virtuosos who drew upon skill, daring and intelligence to perform their jobs. Airplanes eventually became to complex for pilots, as the book illustrates in the case of a once experimental military craft. The pilots who took on the new airplane looked for ways to succeed, and survive, where their successors hadn’t. Rather than more training or expertise, the fallback of many professionals, they looked to the checklist. Use of checklists have become standard in aviation, where it checklist making has been much refined.


An interesting chapter deals with the landing of US Airways Flight 1549 in the Hudson River a few years ago. Dr. Gawande praises the skill of the pilot and crew. He also points out, as the crew of the flight always have, the importance of the procedures they used, and especially the checklists that helped them to implement those procedures.

Through several examples, the outline of what make a good checklist and the cases where they work best are show. There isn’t yet and exact science to making checklists, but there is a well-developed art, which includes testing and revision.

It takes a dose of humility to accept that checklists can help highly trained professionals do their jobs better. Dr. Gawande seems to hope his fellow surgeons can show some the humility shown by pilots and allow checklist to become a tool for improving their work.

I come from a background in engineering and this makes sense to me. A procedure is designed much like anything else. If there are critical elements in anything, it is wise to reinforce them in ways that ensure their performance. The human mind is capable of amazing things, but can’t necessarily be relied on to remember to turn off the lights or stove or do any number of other little things.

I’ve also worked in the regulatory field, and seen thoughtless, narrow adherence to rules bring about undesirable results, sometime contrary to what the rules intended. This is not at all in the spirit of The Checklist Manifesto. A good checklist ensures consistency and quality while at the same time freeing the minds of its users to creative deal with the complexities of their task.

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