'The Checklist Manifesto': a simple, brilliant prescription for getting things right

'The Checklist Manifesto: How to Get Things Right'

Atul Gawande

Metropolitan Books, 209 pp., $24

BOOK REVIEW |

This is a brilliant book about an idea so simple it sounds dumb until you hear the case for it. Atul Gawande presents an argument so strong that I challenge anyone to go away from this book unconvinced.

"The Checklist Manifesto" is about how to prevent highly trained, specialized workers from making dumb mistakes. Gawande — who appears in Seattle several times early next week — is a surgeon, and much of his book is about surgery. But he also talks to a construction manager, a master chef, a venture capitalist and the man at The Boeing Co. who writes checklists for airline pilots.

Commercial pilots have been using checklists for decades. Gawande traces this back to a fly-off at Wright Field, Ohio, in 1935, when the Army Air Force was choosing its new bomber. Boeing's entry, the B-17, would later be built by the thousands, but on that first flight it took off, stalled, crashed and burned. The new airplane was complicated, and the pilot, who was highly experienced, had forgotten a routine step.

For pilots, checklists are part of the culture. For surgical teams they have not been. That began to change when a colleague of Gawande's tried using a checklist to reduce infections when using a central venous catheter, a tube to deliver drugs to the bloodstream.

The original checklist: wash hands; clean patient's skin with antiseptic; use sterile drapes; wear sterile mask, hat, gown and gloves; use a sterile dressing after inserting the line. These are all things every surgical team knows. After putting them in a checklist, the number of central-line infections in that hospital fell dramatically.

Then came the big study, the use of a surgical checklist in eight hospitals around the world. One was in rural Tanzania, in Africa. One was in the Kingdom of Jordan. One was the University of Washington Medical Center in Seattle. They were hugely different hospitals with much different rates of infection.

Use of the checklist lowered infection rates significantly in all of them.

Gawande describes the key things about a checklist, much of it learned from Boeing. It has to be short, limited to critical steps only. Generally the checking is not done by the top person. In the cockpit, the checklist is read by the copilot; in an operating room, Gawande discovered, it is done best by a nurse.

Gawande wondered whether surgeons would accept control by a subordinate. Which was stronger, the culture of hierarchy or the culture of precision? He found reason for optimism in the following dialogue he heard in the hospital in Amman, Jordan, after a nurse saw a surgeon touch a nonsterile surface:

Nurse: "You have to change your glove."

Surgeon: "It's fine."

Nurse: "No, it's not. Don't be stupid."

You want to cheer for that nurse.

Highly intelligent and trained people are, occasionally, stupid. And the more complicated tasks become, the easier it is to crash and burn with even a 1 percent error rate on each step — because there are so many steps.

Gawande has written a short, readable, sensible book and is highly recommended.

Bruce Ramsey: bramsey@seattletimes.com