Book review: The Checklist Manifesto: How to Get Things Right by Atul Gawande

A couple weeks ago a friend raved about a book. He explained that The Checklist Manifesto had insights to avoiding problems. I borrowed the book from the library and was blown away by some of the ideas. Now I’ll buy the book and review it with my children.

Early in the book the author makes a fascinating point. His analysis of the source of mistakes is that broadly there are two basic reasons why we make mistakes. The first major reason for many errors is because we don’t know enough. If we have only an introductory education on how to drive a car or write software we can often make simple blunders that more experience will teach us to avoid. The second major source of mistakes is we are careless. This turns out to be a major source of faults when there is great complexity.

Atul Gawande is a doctor and much of this book is about the complexity of medicine. Dr. Gawande explains that medicine has become the art of managing extreme complexity. Currently there are over 13,000 different diseases, syndromes and types of injuries. Imagine that! Trying to stay on top of even a fraction is an almost impossible job. At one clinic the average doctor had to deal with over 250 primary diseases and conditions in a year.

With the increase in complexity comes the greater chance for mistakes. For example in the United States there are over 150,000 deaths each year for people who have gone through surgery. Research indicates that over half of those were avoidable. People die from mistakes! In a typical day a person recovering from surgery may need 180 different specific actions. If one of them is missed or done wrong the patient might die.

Dr. Gawande switches from medicine to airplanes. In 1935 Boeing was demonstrating their new bomber the B-17 to the Army Air Corp. The generally accepted belief was Boeing had it in the bag. The plane could carry five times the as many bombs as the Army had requested. It was designed to faster and farther than the competition. Yet the plane crashed right after take off. They had invested heavily in developing the B-17; the lost of the contract almost killed Boeing. They launched a major investigation into the crash. Why was there a crash? They went over every piece of wreckage. They came to a surprising conclusion. While they had one of the best test pilots in the industry it appears that the B-17 was too complex to fly. There were many, maybe too many, things to keep track of. If the pilot missed one of them the plane might crash. A key result of this investigation was the widely adopted use of the checklist. Now before every flight a pilot reviews a checklist and airplane accidents are very infrequent.

The author breaks down problems from another approach. He shows how there are three types of problems. The first type of problems is simple problems which can be solved by a recipe or formulae. The second type of problems is more complex problems, but repeatable, like flying to the moon. Fundamentally these complex problems can be reduced to a large set of simple problems; each is solvable with a well understood recipe. The last type of problems is non repeatable complex problems, like raising a child. The fundamental problem is the solution for one problem may not work for another similar problem. Parents face this all the time, discipline and rewards work differently with each child. Checklists don’t solve all problems, but they help tell which problems are appropriate.

Much of this book is about a surgery process improvement team Dr. Gawande was contributing to, and how they decided to recommend the use of checklists with surgery. They found that it was important to consider what goes on the checklist and what doesn’t go on the checklist. They drew heavily from the airplane industry. For example you don’t need to tell the surgeon to breath, he does that automatically. The checklist shouldn’t be too long, because people will tend to skip steps or toss it out completely. The team noticed that few mistakes happened with a well functioning surgery team, but at most hospitals the teams were formed and reformed for almost every surgery. It was hard to have each surgery team function as a cohesive team. They tried to encourage this by including on the checklist a step where each team member would introduce themselves. The result was the teams become more united and covered each other. Nurses felt freer to point out to a surgeon when they skipped a step. This single item lead to a huge decrease in the complications and deaths after surgery.

The book also explores how checklists get used effectively in other industries like building construction, and to some extent investing.

This is a fascinating book and well worth reading, probably worth reading twice.