Why are checklists important?
Atul Gawande: Yeah, I mean, I wrote a whole book on checklists. You'd be -- you know, why in
the world would anybody write a whole book on checklists? And it was the last thing I thought I
would be writing about. But I've been fascinated by how we grapple with risk and complexity in
medicine, and I got assigned a project to try to find a way to reduce deaths in surgery. We have
been struggling with our performance, and so I started looking at how people in other fields
grapple with the enormously increasing complexity that people in professional worlds are
dealing with. And what I found was -- in aviation, in skyscraper building and other lines of work
-- that there was something really fundamental going on; we had transformed from a world
where ignorance was our biggest struggle as human beings -- this is the way it was for millennia;
we didn't understand why the human body fails, how to build things really well, how to do many,
many kinds of tasks in the right way; that knowledge was missing.
Today, however, our biggest struggle is with what people call ineptitude, meaning the knowledge
is there, but somebody's not doing it right. And in surgery, in other parts of medicine, what we're
finding is that the amount of knowledge, the volume, the complexity, the tons of papers coming
across the transom, the technologies that are proliferating -- that all of it has exceeded our
abilities as individuals to hold it all in our head and do it right. And there are lots of fields, it
turns out, where this has been happening: constructing buildings well, making good investment
decisions with our hedge funds. And when I looked to see how people who actually are solving
these problems were solving it, I thought you'd find that they had just trained in a different way,
or they were training longer and harder, or they had a different kind of use of technology.
Instead, what I found over and over again was, they used checklists, as simple and mundane as it
sounds; that the checklists in a way filled in for weaknesses in people's brains, things that they
forgot. It also filled in for weaknesses in making teams work. Teams constantly drop stuff
between the cracks, and so we made a checklist based on what I learned. Actually, I got folks
from Boeing to help us out. How do you make a checklist? I didn't think that that would be all
that hard. It turned out to be hard.
And one of the things they showed us was how to really focus on making it swift and usable. We
made a two-minute surgery checklist; it had just 19 items. Some of them were just make sure you
don't forget dumb stuff: make sure you gave antibiotics, make sure you have blood ready for a
high-blood-loss case. And then there were other interesting parts: make sure everybody in the
room has been introduced by name and role; make sure the surgeon actually explained to the
team what their goals for the operation are; make sure the anesthesiologist and nurses had a
chance to explain their plans for the operation. We put that checklist in eight hospitals around the
world, ranging from rural Tanzania to Toronto and Seattle, and every single hospital we put it in
had a double-digit reduction in complications. The average reduction in death was 46 percent.
That made me realize there was something much deeper and more important going on here about
this set of problems we're grappling with in the modern world.