LEADERSHIP LIBRARY

IN BRIEF

Atul Gawande argues how effective checklists can be, especially in situations that are complex and failures in our unreliable memories could have devastating impacts.

Key Concepts

The checklist is to overcome our human inadequacies

“That means we need a different strategy for overcoming failure, one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our inevitable human inadequacies. And there is such a strategy—though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies. It is a checklist.” (p. 13)

Though experts are increasingly specialized, there is too much information to prevent mistakes

“The knowledge exists. But however supremely specialized and trained we may have become, steps are still missed. Mistakes are still made. ...What do you do when even the superspecialists fail? We’ve begun to see an answer, but it has come from an unexpected source—one that has nothing to do with medicine at all.” (p. 31)

Good checklists are precise and simple

“There are good checklists and bad, Boorman explained. Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat the people using the tools as dumb and try to spell out every single step. They turn people’s brains off rather than turn them on.” (p. 120)

Two types of checklists

“With a DO-CONFIRM checklist, he said, team members perform their jobs from memory and experience, often separately. But then they stop. They pause to run the checklist and confirm that everything that was supposed to be done was done.” (p. 123)

“With a READ-DO checklist, on the other hand, people carry out the tasks as they check them off—it’s more of a recipe.” (p. 123)

Quotables

“But sometime over the last several decades—and it is only over the last several decades—science has filled in enough knowledge to make ineptitude as much our struggle as ignorance.” (p. 8)

“In a complex environment, experts are up against two main difficulties. 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. …A further difficulty, just as insidious, is that people can lull themselves into skipping steps even when they remember them. In complex processes, after all, certain steps don’t always matter.” (p. 36) 

“… checklists seem able to defend anyone, even the experienced, against failure in many more tasks that we realized. They provide a kind of cognitive net. They catch mental flaws inherent in all of us—flaws of memory and attention and thoroughness.” (p. 48)

“No, the real lesson is that under conditions of true complexity—where the knowledge required exceeds that of any individual and unpredictability reigns—efforts to dictate every step from the center will fail. People need room to act and adapt.” (p. 79)

 “The investigators at Johns Hopkins and elsewhere had also observed that when nurses were given a chance to say their names and mention their concerns at the beginning of a case, they were more likely to note problems and offer solutions. The researchers call it an ‘activation phenomenon,’ Given people a chance to say something at the start seemed to activate their sense of participation and responsibility and their willingness to speak up.” (p. 108)

“So you want to keep the list short by focusing on what he called ‘the killer items’—the steps that are most dangerous to skip and sometimes overlooked nonetheless.” (p. 123)

“But Boorman was adamant about one further point: no matter how careful we might be, no matter how much thought we might put in, a checklist has to be tested in the real world, which is inevitably more complicated than expected.” (p. 124)

“To be sure, checklists must not become ossified mandates that hinder rather than help. Even the simplest requires frequent revisitation and ongoing refinement.” (pp. 183-4)