The Checklist Manifesto Book Summary, by Atul Gawande

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The Checklist Manifesto is a non-fiction book about how checklists can help save lives. The author, Gawande, shows how checklists increase efficiency and teamwork.

The first instance of a checklist was in 1935, when a Boeing Model 299 exploded during takeoff. The pilot forgot to unlock the elevator and rudder controls before takeoff. This is something that any pilot would do, but this time he simply forgot. In response, the US Army pilots who had purchased several Model 299s decided to create checklists for each flight. Construction builders also use checklists because they have many steps and workers from 16 different trades are involved in construction projects.

In 2007, Gawande was asked by the World Health Organization to develop a worldwide program to reduce incidences of death and injury during surgery. In concert with other physicians and public health officials, he tested a 19-step checklist for surgical care in eight hospitals around the globe. He also studied checklists used in aviation, construction, and business to better understand how they could improve performance in surgery.

Gawande’s book was published in 2011.

Key Takeaways

Philosophers Samuel Gorovitz and Alasdair MacIntyre believe that there are two reasons why doctors fail in their profession. The first is ignorance, which comes from the vast amount of knowledge available today. Doctors have to know how to use cutting-edge technology and information to help people and save lives.

In emergency situations, even the best doctors and nurses can make mistakes and cause harm to patients. To reduce that risk, studies have explored using checklists in hospitals. Some people resist this idea because they see it as an attack on their experience or authority. Checklists also shift power from physicians to nurses by giving them a chance to question the doctor’s decisions.

Not all checklists are created equally. The best ones can be completed quickly, but they also need to cover most of the variables that may arise in a situation.

When communication is a part of the checklist, it creates a sense of investment in and participation with the team. This boosts performance.

Despite the proven effectiveness of checklists, many in the medical field are still resistant to their use.

Key Takeaway 1: Philosophers Samuel Gorovitz and Alasdair MacIntyre believe that there might be two reasons for why doctors fail in medicine: ignorance and ineptitude.

In the 1970s, two researchers identified two types of medical errors: ignorance and ineptitude. Ignorance is a failure to understand or comprehend something properly, while ineptitude is a failure to apply knowledge correctly. Scientific research has improved doctors’ understanding of heart disease and helped them spread awareness about its prevention. Likewise, there’s an abundance of scientifically based information available on other topics like skyscraper construction and weather prediction. However, that doesn’t mean people have stopped making mistakes due to ignorance or incorrect application of important information.

It might be unsettling to think that even professionals can make mistakes, but the reality is that they do. One example of this is in the operating room or on a flight deck. Even with experience and skill, there’s always a chance for failure.

Key Takeaway 2: Advances in all industries, especially medicine, have resulted in a vast body of knowledge that can be overwhelming. This poses the problem of how to effectively use cutting-edge information to benefit the greater good and save lives.

In many fields, people have become more specialized. They’ve spent years focusing on a small part of their field. However, despite the huge amount of information available in medicine and surgery, about half a million deaths occur each year due to surgical mistakes. In order to decrease those numbers and improve the odds for success with surgeries, we don’t need more specialization; instead we should focus on better ways to apply what we already know.

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Improving health and safety outcomes requires a bridge between what is learned in studies and labs, and how that knowledge is applied in context. For example, the World Health Organization has shown that HIV transmission can be reduced by 80% with the use of latex condoms. However, when Peter Buffett (chairman of NoVo Foundation) distributed condoms to sex workers, he found out that awareness of disease transmission only drove up the price of unprotected sex rather than changing risky behavior. The data supported his effort but not necessarily his strategy for reducing risky behavior.

In the past, many people believed that scientific research and new discoveries would improve health care delivery and hygiene practices. However, they were wrong because those discoveries weren’t used in an effective way. For example, in one situation new knowledge was applied to a different context than what it was intended for. In other settings including hospitals with top-notch equipment, error arises from misapplication of old information. Human error is the most common cause of errors in medicine today despite all the research being done on how to prevent them. Checklists can help reinforce even obvious steps by making sure nothing gets missed when there’s a lot going on at once during medical procedures or emergencies.

Key Takeaway 3: In emergency situations, even the most expert practitioners can make any range of mistakes that result from inattention or bypassing steps that they deem to be nonessential.

The number of actions performed in a hospital’s Intensive Care Unit (ICU) is very high, considering the care patients need. Mistakes can happen even when there is a low error rate, and those mistakes have serious consequences. Even though it’s complicated to provide this kind of care, people expect sophisticated and expert treatment because they pay so much for it.

Nurses are expected to be the eyes and ears of attending physicians. Meanwhile, physicians are under pressure because they have too many patients to take care of. They’re also underpaid, which has led hospitals to give them quotas and time limits with each patient. This is a big problem for nurses because it’s hard for them to keep track of everything that goes on in the hospital without enough staff members around.

Doctors and nurses need to be humble in order to do their jobs well. Doing a good job is not just about the doctor’s expertise or knowledge, but also about teamwork. For example, before surgery, it’s important for everyone involved to wash their hands and wear gloves so that they don’t cause any infections. A checklist can help make sure that all of these things are done right. Other examples include making sure that doctors order pap smears or mammograms when needed, which could save someone’s life if there is an issue with those tests being ordered late. Another example would be having specialists review each other’s diagnoses because sometimes what one specialist thinks might be wrong with a patient may actually fit into another diagnosis made by another specialist who sees the patient as a whole instead of focusing on just one symptom at a time.

Key Takeaway 4: To increase the baseline of performance at hospitals, a number of different studies have explored the use of checklists in critical care situations.

Over the last fifteen years, researchers have studied how checklists can be used in critical situations. Peter Pronovost, a critical care specialist at Johns Hopkins Hospital, tested a checklist for putting central lines in surgery patients. The hospital saved an estimated two million dollars and prevented 43 infections over 27 months by using the checklist.

With the increasing number of deaths and costs associated with medical errors, hospitals have begun to use checklists. A checklist is a simple method for applying existing knowledge to achieve better outcomes for patients. Some steps on any given checklist are considered obvious or routine steps, but they’re so important that skipping or poorly performing one of these fundamental steps can lead to catastrophic results. For example, when installing central lines before surgery, a patient needs a sterile drape to cover the incision. Forgetting the sterile drape could result in an infection that leads to death.

Key Takeaway 5: The introduction of checklists in critical care settings has been met with resistance, mostly from physicians, who sometimes see the routine procedure as an affront to their experience and authority. Checklists have also helped shift the balance of power in surgery teams, giving nurses room to question the physician.

Doctors have more training than nurses and physician assistants, so they may view a checklist as unnecessary paperwork. This could be because of the shift toward democracy in society, which is characterized by less hierarchy and greater power for average citizens. The popularity of social media exemplifies this trend. In publishing and entertainment, the old-guard arbiter has been greatly diminished with crowdsourcing platforms that give rise to more populist means of art and expression. Therefore, it’s no surprise that workplaces are adjusting to accommodate less hierarchical methods.

Checklists are similar to expert opinions in that they reduce the need for expertise. They’re used in hospitals and other settings where teamwork is crucial, because they help people work together more effectively. Checklists make nurses feel more equal to doctors, which makes them speak up if a doctor isn’t washing his or her hands or giving the right medication.

Key Takeaway 6: Not all checklists are made equally—the best checklists are efficient and can be completed quickly, but are also comprehensive enough to address all, or most, emerging complexities and variables.


Writing a good checklist is not easy. It can be too long or too complicated, which makes it difficult to follow and therefore will likely be ignored. A good checklist must include the most important points of a procedure, as well as being concise.

The underlying notion of checklists is simple, but creating a good checklist isn’t. If there’s something that needs to be done in order for the task at hand to be completed, then it should be included on the checklist. However, if the person using the checklist doesn’t understand what’s being asked of them or how to complete that step, then they won’t use it and will fail at completing their task properly. For example, if someone was trying to write instructions on how jumpstart a car with jumper cables and used technical terms like “mechanical parts” or assumed that people knew whether or not the car should have been running when connecting those cables together (which would lead one to believe they know more about cars than they really do), then those instructions wouldn’t help anyone because no one would bother reading them. The list itself is useless unless everyone can follow along with it without having any questions unanswered or any steps skipped over. As in other settings where checklists are important (like surgery), following an orderly process from beginning to end is crucial for success.

Key Takeaway 7: When communication is part of the checklist, it creates a sense of investment and participation on the part of the individuals involved. This in turn boosts the team’s overall performance.

The World Health Organization wanted to find out if introducing team members would improve the quality of care. They discovered that when they introduced themselves, nurses were happy and doctors tended not to like it. When they analyzed their findings, they found that the quality of care had improved dramatically in all eight hospitals involved in the pilot program.

Communication is essential to success. In a world where specialization and expertise are greatly valued, there’s also less focus on communication between team members. Effective communication includes vulnerability—team members must be willing to admit what they do or do not know, or when they have made mistakes. Likewise, constructive feedback can transform potential failure into success.

Key Takeaway 8: Despite the proven efficacy of checklists, many in the medical field continue to resist such a simple solution to increased performance.

In 2008, the results of a pilot study at the World Health Organization (WHO) were released. The results proved to be successful with surgical complications dropping by 36% in three months as well as death rates falling 47%. This led many countries to adopt checklists for surgeries and now 10% of US hospitals have adopted them too. However, there is still resistance due to surgeons’ egos and people’s reluctance to change despite evidence that shows they’re beneficial.

Changing an institutional culture is a long process. It requires lots of work and the ability to persuade people. While it may seem like evidence-based data or proposed changes would be enough to persuade physicians to adopt a new way of doing their jobs, the reality is that the time between identifying a proven methodology, such as surgical checklists, and a wholesale embrace of such practices can actually be rather long.

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Other doctors have noted that checklists might not be the solution to all problems. In January 2015, a study was released showing that surgical checklists were ineffective in Michigan hospitals. Despite the evidence-based support for using checklists, there is still some debate over how and if they should be used as a standard part of care.

Book Structure

Atul Gawande’s The Checklist Manifesto is a journalistic investigation of why checklists are so effective. He starts off with a personal anecdote about his own failures as a surgeon, and then he goes on to describe how checklists have been used in other industries, such as aviation and construction. His passion for the checklist is evident—he outlines not only the statistical case for using checklists but also their larger implications on teamwork and discipline.

Gawande’s curiosity and enthusiasm make his style engaging, and he puts forth the case for using checklists methodically and sensibly. He demonstrates that mistakes happen all the time, but with checklists we can avoid them. The book is focused on an objective task of utilizing the efficacy of the checklist, but Gawande writes about it in a personal way by injecting his own thoughts into it.

About the Author

Dr. Gawande is a trained surgeon who has been working for many years to remove cancers of the endocrine gland. The Checklist Manifesto evolved out of his personal and professional interest in error reduction, which he studied through both philosophical research and direct observation.

Full Summary of The Checklist Manifesto

“The Problem of Extreme Complexity”

People like to think that they are in complete control of their lives, but this is not always true. Sometimes things don’t go as planned and people fail at what they set out to do. In addition, there are certain areas where humans cannot succeed no matter how hard they try or how much experience they have. This happens because some things are simply beyond the abilities of even the most skilled professionals. For example, it’s impossible for experts to predict violent weather conditions with any degree of accuracy or perform lifesaving surgery on everyone who needs it.

There are two reasons why people fail: ignorance and ineptitude. Ignorance stems from the fact that there’s still a lot to learn about how the world works. Ineptitude occurs when knowledge exists but it isn’t applied correctly. For example, in medicine, research has illuminated staggering amounts of knowledge about human health; however, this information is often not applied consistently or correctly.

Despite advances in technology, mistakes are still made on a daily basis. For example, there could be errors with software design or legal issues with fiscal systems. There have been many weather disasters that were mishandled by professionals as well. The author makes the point that it’s easier to forgive those who make mistakes due to ignorance than those who don’t use existing knowledge properly and cause harm. In order to avoid making these types of mistakes, you should use checklists for everything you do because they’re so effective at helping people perform tasks correctly every time without forgetting anything important.

The Checklist

A three-year old girl fell into a pond and was underwater for 30 minutes. Her parents pulled her out, but she had no signs of life when the rescuers arrived 8 minutes later. Nonetheless, they airlifted her to the hospital where doctors cut open her chest despite being lifeless for 90 minutes. The machines kept blood flowing through her body as it warmed up to normal temperature after 6 hours. After two days, all organs except the brain returned to normal function. She remained in a coma for more than a week before undergoing extensive rehabilitation that fully restored her by age 5 years old. The lead surgeon attributed their success with checklists reminding them of every step needed to prepare themselves during an emergency situation upon arrival at the scene of an accident or disaster such as this one described here

In 1935, the US Army Air Corps asked for designs for a new long-range bomber. Boeing’s design had the lead but crashed during testing. The veteran pilot who died in that crash forgot to release a lock and caused the plane to stall. Rather than redesigning or changing training, some test pilots developed an index card checklist of steps that flyers would go through before takeoff. Using this checklist saved Boeing from bankruptcy and led to the B-17 bombers which fought Nazi Germany in World War II without any accidents over 1.8 million flight miles!

Many professionals face the same challenges as those test pilots did in 1935. They have to deal with too much information and distractions, which can make it difficult for them to remember every detail. If they miss just one thing, their task will be incomplete. Checklists help solve this problem by making sure that professionals don’t forget anything important when they’re working on something complex.

“The End of the Master Builder”

Until the mid-20th century, there were Master Builders who designed and engineered buildings. These craftsmen oversaw every aspect of a building’s construction from start to finish. However, advances in technology have made it impossible for one person to master all aspects of building design. Thus, the profession has split into architects, engineers and contractors each with their own specialties and subspecialities that they use checklists to ensure projects are completed correctly.

No one authorizes or performs a task, no matter how small, without checking if preceding tasks are complete. Contractors use large wall-mounted paper charts to track each step visually as it happens and they also use project management software and communications systems. That’s now the industry standard because of an analysis by researchers that found that there were only 20 serious building failures per year in the US out of millions of buildings built per year with an annual avoidable failure rate of less than 0.00002%. Checklists work.

The Idea

Builders are known for their ability to deal with unanticipated events and situations. They empower their workers in the field to make decisions. On the other hand, managers tend to be more controlling and give out checklists instead of trusting employees to make important decisions on their own. When Hurricane Katrina hit New Orleans, FEMA officials were unable to adapt quickly enough because they didn’t trust local authorities and kept making bad decisions themselves.

Walmart’s response to Hurricane Katrina was a success. The company gave local store managers full permission to do whatever they could to help the victims of the hurricane. Some managers even gave away all their inventory, while others gave first responders food and other supplies. Senior executives focused on communication rather than issuing orders so that no one missed anything important or failed to communicate effectively with each other as they worked together in resolving the crisis.

“The First Try”

In 2006, Dr. Atul Gawande and his team discovered that surgical complications lead to millions of deaths around the world each year. They joined a WHO group to find solutions to this problem, but rejected most possible remedies as unfeasible. However, after studying checklists used in health care settings for some time, they decided that was the way forward.

In one case study, they distributed bars of antibacterial soap to poor neighborhoods in Karachi, Pakistan. They taught the residents how to use it correctly and often enough. During this time period, there was a 35% decrease in skin disease impetigo and 48% drop in pneumonia among children. The participants already used bar soap at home but not correctly or often enough.

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Another example of the power of checklists comes from a hospital in Columbus, Ohio. There, doctors were using antibiotics improperly on patients because they didn’t follow a checklist. By putting a checklist into place and giving nurses more authority to hold surgeons accountable for following it, the problem was solved. This is an excellent example that shows how checklists can improve teamwork and results.

“The Checklist Factory”

Veteran pilot Daniel Boorman, who spent 20 years creating checklists and flight deck controls for Boeing, warns against bad checklists that are vague and imprecise. Conversely, good checklists are precise, efficient, to the point and easy to use in even the most difficult situations. When compiling a checklist don’t spell out every single step in bureaucratic detail; use simple words in the lingo of your field. Fit your list on one piece of paper and use both upper- and lowercase type (preferably sans serif). Test and refine your checklist in the real world.

Checklists are very useful and important. They help us to stay on track and focus on the most critical items. The best checklists have a “killer item” that is crucial for success, but often overlooked by people in their daily lives. Boeing uses two types of checklists: DO-CONFIRM to verify whether pilots carry out certain actions correctly, and READ-DO which tells pilots what they need to do while carrying out an action. However, no matter how good the checklist is, it can’t force anyone to use it if they don’t want to or aren’t willing. Many surgeons don’t like using checklists because they think that it will take away from their ability to be creative and remember things without writing them down. But being creative doesn’t mean you won’t make mistakes! Good doctors know this so when faced with a crisis they actually use their checklist instead of trying other methods first (like taking more time).

“The Test”

The World Health Organization (WHO) met in Geneva to discuss the safe surgery checklist. They cut out unnecessary items and reduced it from over 30 items to 19, which were then tested in 8 hospitals around the world. The results showed that by using this new checklist, surgical complications decreased by 36%. ”Pockets of resistance notwithstanding,” every hospital had adopted the checklist within a month of its introduction.

After implementing a checklist in their operating rooms, the World Health Organization (WHO) saw major improvements. Complications dropped by 36%, deaths by 47%, infections by nearly 50% and follow-up surgeries to correct problems decreased by 25%. Only 277 people had serious complications compared to 435 before using the checklist. The WHO found that 80% of staff found the checklist easy to use and 78% saw it prevent surgical mistakes during operations.

“The Age of Checklists”

Many hospitals are using checklists now, and more than 2,000 hospitals use them around the world. The reason is that they help to prevent mistakes. Furthermore, investors who have been successful attribute their success to using a checklist based on experience and research of respected peers. Warren Buffett also uses a mental checklist process when making decisions about his investments.

Although people need help to be disciplined, they’re not very good at being disciplined. Therefore, it’s hard to introduce the discipline of checklists in other fields. People don’t do research on why certain things keep happening over and over again. That’s why we should try a checklist approach instead of trying the same thing repeatedly.

The Checklist Manifesto Book Summary, by Atul Gawande

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