The Checklist Manifesto: Roger Roger

71CwWiCJhuLBeing a pilot you are raised on checklists, so it really came as a surprise to me that this seemed to be new information for people, particularly those in the medical field. After all, wouldn’t you want to know that the doctor checked to make sure you were knocked out before he took a gigantic knife and sliced you from stem to stern? I know I would.

But checklists and their use is exactly what Dr. Atul Gawande explored and helped pioneered in the field of medicine. His book, The Checklist Manifesto: How to Get Things Right explains how checklists should be developed and used, and when they actually hinder performance.

We hear stories all the time about doctors who operated on the wrong foot or the wrong leg, or took out the wrong body part. We also see failure in many areas of life which leaves us wondering: why do we still fail when there is so much information available to us?

To a certain extent, some failure is necessary fallibility – some things are simply beyond our capacity and even technology has not brought our physical and mental powers to where they need to be for us to be omniscient or all-powerful (Gawande 7-8). But, there are many things that are completely within our control, so why do we still fail at “the little things,” (like removing the wrong body part).

  • Ignorance: we make errors because we still only have a partial understanding of the world and how it works (Gawande 8). We still cannot accurately predict a snowstorm every time, nor have we learned to completely stop heart attacks from happening, however we do know how to manage these two events. I have to laugh a little bit when I hear scientists making definitive conclusions about life and environments on other planets, when it seems we discover something new about our own planet every day, and we live here!
  • Ineptitude: this means we have the knowledge but we fail to apply it correctly (Gawande 8). This is where the rubber meets the road.

If you think about it, for much of human history we really had no idea what we were doing. 100 years ago if you had a heart attack the doctor could shake a stick and go Hooga Booga and if you got better then you left some money on the table but if you died then it was “next patient please.” Today, there are numerous ways to reduce your likelihood of having a heart attack and of mitigating the actual attack itself (Gawande 9). So why do people still die of heart attacks?

Gawande calls it a problem of “eptitude,” making sure we apply the knowledge we have, consistently and correctly (Gawande 10). The big problem we have today is that we have more knowledge than the human brain can really handle all the time and apply all the time. We can think big thoughts and do amazing things and still forget some small step that leads the whole thing to disaster.

Medical errors, lawsuits, legal errors, administrative errors, flawed software design, you name it, mistakes happen in almost any endeavor that requires mastering complex and large amounts of knowledge (Gawande 11). Not knowing what to do is somewhat forgivable. But knowing what to do and then not doing it right, is infuriating (Gawande 11).

As I said, the solution lies in the simplicity of the checklist. But as we will discover, checklist design is not always so simple. I tend to travel a lot for my profession and as such and prone to forget things to pack from time to time. Originally, I assembled a check list that included everything that I needed to take right down to the number of socks. After just a few trips I tossed that list – it was too long and onerous.

I also found that the list still did not ensure I had packed everything! And this is the challenge with checklists: you have to know what you need a checklist for and what needs to be on it. Then you have to use it. The other problem I had with the checklist is it was not practical to check an item off as I packed it, that was taking forever, but if I reviewed the checklist after I’d packed to ensure that everything had been packed I started to question myself and would end up unpacking my suitcase just to find an item I could not remember if I packed. It was exhausting.

I realized that the vast majority of things I pack, I pack consistently and without forgetting them. I do it without even thinking about it. But there are still always those items I am prone to forget. I eventually created a checklist of the items I most often forget. This is the only list I check before going on travel and I never forget those key items.

It was astonishing to me that clinicians now have some 6,000 different drugs and 4,000 medical and surgical procedures, each with different requirements, risks and considerations to treat an individual’s illness or injury (Gawande 19). That is a lot to remember but I guess that’s why surgeons make the big bucks. Actually, the medical industry has seen much more specialization as the breath and quantity of knowledge that is required for these medical procedures is both vast and complex. Quite simply, it’s impossible for one person to remember all of this.

As far along as medicine has come there are still more than 150,000 deaths following surgery every year which is triple the rate of road traffic fatalities (Gawande 28) and the research has shown that at least half of these deaths and major complications were avoidable  (Gawande 28). An average patient in intensive care can require up to 178 or more individual actions per day, from administering drugs to suctioning the lungs, and each action poses risk’s  (Gawande 23-24). While doctors and nurses in this study were observed to make an error in just 1% of these actions that still amounts to two errors a day per patient. On average over 90,000 people a year are admitted to intensive care. You do the math. Maybe a checklist isn’t such a bad idea. Where in your life could you see a checklist helping out?

Gawande, Atul. The Checklist Manifesto: How to Get Things Right. New York: Metropolitan, 2010. Print.

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