The Checklist Manifesto: How to Get Things Right

In 2006, Gawande was asked by a representative of the World Health Organization (WHO) to help investigate and develop protocols to reduce “avoidable deaths from surgeries” (86). Gawande shares statistics regarding how many people receive surgery worldwide, and how many of these people have negative experiences from surgery, including death. He contends that because of the sheer amount of surgeries being performed, it is likely that without a universally accepted system in place, negative outcomes could continue. He discusses his participation in a two-day Geneva conference in 2007. People from around the world chronicled the various issues they experienced in their native countries when it came to surgery. These problems ranged from lack of access to surgery itself, lack of qualified personnel performing complex surgeries, and an overall discontinuity between surgeons, nurses, and anesthesiologists. While participants generally agreed that surgery should be available to all, even if performed by underqualified doctors, the high rate of complications from surgeries, some five to fifteen percent worldwide, was unacceptable.

Those at the conference discussed possible approaches to remedy the situation. Possible solutions included more training (which was dismissed), incentive programs for surgeons (which was deemed unreliable), and the establishment of an official standard of surgical care. The last approach was generally agreed upon, but Gawande worried about feasibility. He delves into how a cholera outbreak in London in 1854 was traced to a single well. Once the well was shut down, the outbreak ended. Gawande then discusses an experiment conducted by public health expert Stephen Luby in Karachi, Pakistan. Luby persuaded health-based corporation Proctor & Gamble to donate a new soap they developed and promised would protect against bacterial infection. As the program was launched in some of Karachi’s impoverished neighborhoods, maladies such as diarrhea and pneumonia all decreased dramatically. Both the new soap and its instructions detailing proper hand-washing helped.

Gawande discusses three places where checklists proved effective at reducing complications from surgery: Johns Hopkins, University of Toronto, and a group of hospitals in Southern California. Though the results of using checklists in these three places were promising, Gawande recognizes that oftentimes, checklists decentralize authority, and this can be problematic for a head surgeon. Gawande discusses how the checklist helps forge a better sense of teamwork and ultimately democratizes surgery; nurses have the authority to verify a list just like a surgeon has the authority to make incisions. The checklist makes a surgical procedure far more team-oriented. Gawande goes on to discuss perceptions among surgical professionals, including nurses and anesthesiologists, and cites studies that show a discrepancy between surgeons and other professionals’ perception of a completed surgery.

Gawande recalls a story from his own experience in which an 80-year-old patient needed life-saving surgery on his colon. Everyone involved in the procedure acted their part, and in the end, Gawande says all six members of the team acted as one. He confesses that he is uncertain what causes such unity, but insists that when everyone involved in a surgery feel part of a team, the chances of mistakes are reduced. He returns to the conference in Geneva, in which it was agreed that a checklist for safe surgery practices should be designed. It was decided that there should be three “pause points” during which a checklist is performed: before the application of anesthesia, before the incision, and after the operation concludes. When Gawande returns to his own hospital, he is excited to implement his checklist. However, he found that the checklist itself was faulty, mainly because it lacked specificity and clarity, which meant it would likely affect other hospitals where it was implemented.