Category: Science

One of my personal goals for 2014 is to read a new book every couple of weeks. This is the second book I’ve read this year. The Checklist Manifesto: How to Get Things Right, by Atul Gawande.

Why did I read this?

I read this because I first read Atul Gawande’s article The New Yorker, titled simply The Checklist. The article was surprisingly captivating, so when I found out that Gawande had expanded the article into a full book, I had to read it.

Summary

The Checklist Manifesto is subtitled “How to get things right,” which is  a good summation of the book all by itself. It examines scenarios that are prone to human error, even when those humans are experts at the top of their fields, and how the simple use of a checklist can greatly reduce the error in those situations.

Drawing on examples from aviation, construction, medicine (the author is a surgeon “in real life”), investment banking, and other fields, Gawande shows how checklists have been used to eliminate error.

He describes being recruited by the World Health Organization (WHO) to come up with a plan to improve surgical outcomes worldwide. They decide to experiment with a checklist, asking surgeons in some hospitals to use a pre-surgery checklist in their operating rooms. After Dr. Gawande tries using the checklist himself in his own practice, he finds it cumbersome, confusing, and impractical. He takes a trip to Seattle, where he visits with Daniel Boorman, a Boeing technical fellow, who is responsible for the creation of checklists used by pilots flying Boeing’s airliners.

(Checklists as a tool for professional discipline were born from aviation, even from Boeing: In 1935, a pilot demonstrating Boeing’s newly designed bomber to the Army Air Corps crashed on takeoff, killing himself and two others. He crashed because he had forgotten to release a lock on the airplane’s elevator and rudder controls. The airplane was dismissed as “too much plane for one man to fly,” and the military nearly ended the project. Test pilots, however, thought the airplane was marvelous, and worked together to solve the “too much plane” problem. Their solution was to create a simple set of checklists: One for before takeoff, one for flight, one for approach, and one for landing. With checklists in hand, the test pilots then flew the airplane more than 1.8 Million miles without a single accident. The army ordered 13,000 airplanes, and dubbed it the B-17, now one of the most celebrated bombers in military aviation history.)

Boorman teaches Gawande some of the important things Boeing has learned about checklists: They should use natural breaks in the workflow. They should be relatively short (5-9 items). They should be printed in black & white in a sans-serif font….And more. Boorman then takes Gawande into a hyper-realistic flight simulator, helps him taxi the airplane to a runway and take off, all using the same checklists that pilots use. Then, as their flight ascends through 20,000 feet, a warning light comes on in the cockpit. Gawande’s airplane has a door that appears to not be latched properly. This situation can be deadly (In 1989, this exact situation led to an “explosive decompression” of a United Airlines 747, killing 9 passengers). Gawande, remembering his few minutes of pre-flight training, grabs an emergency procedures book, turns quickly to the checklist for the DOOR FWD CARGO warning light, and follows it. Their simulation flight is able to land safely.

(As an aside, I’m totally jealous that Gawande got to “fly” a full motion 777 simulator. I would LOVE to do that.)

Gawande takes his newfound understanding back to the WHO, where they redesign their surgical checklists following Boeing’s principles, and run a test in 8 hospitals around the world. The results are astounding. They achieve double-digit percentage reductions in complications, infections, and other scary surgical by-products, including death. By his calculations, during the three-month trial in 8 hospitals, the checklists prevented 27 unnecessary deaths.

In the end, Gawande describes an incident in his own operating room where, by his own description, he tore a patient’s vena cava (the largest vein in your body, which bring blood from most of your lower half to your heart). The bleeding was, in Dr. Gawande’s own words, “terrifying.” In seconds, he had opened the patient’s abdomen and chest completely, and was holding his heart in his hands, pumping blood through it while another doctor put pressure on the torn vein. The patient was losing blood a rate measurable in gallons.

One of the items on the surgeon’s pre-incision checklist is to discuss with the operating room team the possible blood loss in the operation. Then, the head nurse calls and confirms that the hospital’s blood bank has enough blood ready to use to cover the worst case scenario (the blood bank is supposed to do this already, without the nurse having to make the call). Gawande’s team had followed the checklist. When the nurse called the blood bank, it was discovered that the blood for this operation was not ready, so the operation was held up a few minutes while the blood bank prepared.

Now, Gawande has the patient’s heart in his hands, and can feel it emptying out like a deflating balloon, and in seconds, the blood from the blood bank is being transfused into the patient. The blood that wouldn’t have been ready to use if the team hadn’t followed its checklist.

By the time the vein is repaired and the patient’s heart is beating on its  own again, 30 “units” of blood have been transfused (keep this in mind: an adult body holds about 10 units: This patient bled 3 times his own blood volume). The patient lived, and while there were some side effects of the incident, recovered. Dr. Gawande is 100% certain that without the checklist, the patient would have died on the operating table while they waited precious minutes for the blood bank.

What did I think?

It’s hard to imagine a subject duller than checklists. Yet Gawande is a good writer, and fills the book with powerful narratives. Whether recounting incredible medical recoveries, telling what happened in the cockpit of USAir 1493 as it crash-landed in the Hudson river, or describing the qualities of a well-written checklist, his writing is engaging.

As for the book’s subtitle “How to get things right,” we’re given a few insights into how to get things right in our own worlds, like the difference between simple, complicated, and complex tasks, and how checklists can (and can’t) help with each (For example, there will be no checklist for raising a child, but there can be one for making sure a child has good nutrition), but I would have liked a little more of the “how to” material.

Ultimately, I was surprised that I found The Checklist Manifesto hard to put down, and when I turned the last page, I wanted to read more.

Would I recommend it?

Here’s the test: Go read The Checklist. If you enjoy it, you’ll like The Checklist Manifesto. I did.