The Checklist Manifesto- How to Get Things Right


I read this book in just two weeks and must say am pretty impressed with the credentials of the author. Dr. Atul Gawande is a MacArthur Fellow, an endocrine surgeon, a staff writer for The New Yorker, and an associate professor at Harvard. He also leads the World Health Organization’s Safe Surgery Saves Lives program and is a published author. Taking his first-hand experience in the surgery ward, he tries to convince his readers through extensive research how a checklist can save lives in the medical field.

Gawande starts his thesis by opining why checklists are critical and preventing in human fallacies. He thinks that no matter how experienced or specialized a surgeon is how much the procedure’s knowledge exists, it is only realistic to assume that minor steps can be missed resulting in declining success rates. So what does he propose? Checklists!!! Yes, simple, bulleted, and succinct checklists. Why and do they work? That’s the journey you take while reading the book.

During his research, he found that the first modern-day example of a checklist being used in a profession was in aviation. Pilots made their lists “simple, brief, and to the point-short enough to fit on an index card, with step-by-step checks for takeoff, flight, landing, and taxiing”. And as successful that was for the first pilots, it came with its own challenges. “Mapping out the proper steps for every case is not possible” and especially in the medical field, where there are hundreds of diseases and procedures, “physicians have been skeptical that a piece of paper with a bunch of little boxes” would save lives. So what do we do about that? Include teamwork and communication!

Instead of making an impossible standard list for ALL the procedures, have nurses and doctors create their own checklists for each procedure. Another point he raises is that during a procedure there needs to be communication and check-ins with all the participants (patient, surgeon, doctors, nurses, etc.) so they are all on the same page about the desired outcome.

He is also honest about the challenges of incorporating checklists in hospitals that don’t use them already and checklists’ own shortcomings. Surgeons were offended that they needed checklists, nurses raised questions whether it was logistically possible, and many of them opined that for complex problems, checklists are not enough. Gawande continues. He brings in another example of checklists’ successes in real life. Construction sites! He pens down example of one construction business that uses two types of checklists. One checklist is procedural and one checklist is purely for communication check-ins. And because of these two bulleted pieces of rather large pages (it’s for a building construction), they are able to complete each task efficiently and seamlessly.

The use of checklists can be applied to global health problems as well. He gives one example when he worked for a world health organization looking for ways to control infections after surgical procedures. One example I liked (because it is about Karachi) is how the volunteers passed out soaps to slums and instructed the families how to use it and when to use it. This systematic approach helped everyone in those slums and incidences such as diarrhea fell 52 percent, pneumonia fell by 48 percent and there were other drops as well.

Towards the end of the book, he writes a revised description and intention of having checklists in a surgical room. He says that not each checklist should have all the steps of a procedure-that is limiting and unrealistic. We need to make the surgeons and doctors make their own trained decisions on what to do in certain cases and checklists must only “provide reminders of only the most critical and important steps-the ones that even the highly skilled professionals using them could miss”. They should not be longer than a page and should be tested in a real-life procedure. So what items need to be on these checklists? Steps like washing hands, putting a mask on, asking a patient’s name, communicating with all the nurses about the nature of the surgery and so on. As Gawande puts it, checklists are “quick and simple tools aimed to buttress the skills of expert professionals” and are “encouraged to [be modified] to fit into [a surgeon’s] usual procedures”.

So what do I have to say about this book? Well, it is quite descriptive in nature as it goes deep into medical procedures, proving that its author is a surgeon. Like a surgeon, Gwande does deep (no pun intended) into this issue and uses case studies in which checklists actually help people around the world and across professions. The book is sort of an editorial plus textbook. It is full of facts, real-life events but, he does include his own experiences and opinions. I liked it. Happy Reading!

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