In the book “The Checklist Manifesto: How to Get Things Right, Atul Gawande, surgeon and best-selling author, tackles the problem of how to prevent human error in an age where professionals grapple with the increasing complexity of their responsibilities. Errors, he postulates, can be caused by ignorance (mistakes we make because we don’t know enough) or because of ineptitude (mistakes we make because we don’t make proper use of what we know). Failures in the modern world increasingly seem to result from ineptitude. This certainly seems true for process safety incidents (like level overflow incidents) which we seem to repeat, even though we have well-documented case studies (e.g., Buncefield).

He walks through case studies in medicine, construction, finance, and aviation to document the need for and the benefits of the checklist. In one example he worked with the World Health Organization (WHO) to develop a safe surgery checklist that could be used in any hospital around the world. After years in the making, they settled on a checklist of 19 steps:

  • Seven checks before anesthesia – confirming patient identity, consent, marking the surgical site, checking for allergies and availability of blood and equipment.
  • Seven checks after anesthesia and before the incision – checking that all team members know everyone, checking that they have the right patient and correct procedure, checking that antibiotics have administered, that radiology images are available and that everyone knows what will happen during the operation.
  • Five final tests before the patient leaves the room – if all sponges and instruments are present and accounted for, plans and concerns for patient recovery.

This safe surgery checklist was rolled out to eight hospitals around the world, beginning in spring 2008. The results of this pilot study were compelling:

  • Major surgery complications at all eight hospitals fell 36% after the introduction of the checklist.
  • Deaths fell by 47%; from 435 to only 277.
  • Infections fell almost by half.

Some very relevant lessons on how to make an effective checklist came from his interview with Daniel Boorman of Boeing, who has spent his entire career working in human factors and developing checklist handbooks / operating procedures. Key takeways include:

Bad Checklists

Good Checklists

  • Are vague and imprecise
  • Are too long
  • Are hard to use
  • Are impractical
  • Are made by “desk jockeys” with no awareness of the situations in which they will be deployed
  • They treat the people using the tools as dumb and try to spellout every single step
  • They turn off people’s brains rather than turn them on
  • Are precise
  • Are efficient
  • Are easy to use, even in the most difficult situations
  • They do not try to spell out everything
  • They provide reminders of only the most critical and important steps; the ones that even highly skilled professionals could miss.
  • They are PRACTICAL
  • Can help experts remember how to operate a complex process
  • Can make priorities clearer and prompt people to function better as a team

Tips for creating a checklist (Work Instruction or Procedure)

  • When: define a clear pause point / initiating event when the checklist should be used (if not obvious)
  • Format: either a DO-CONFIRM checklist or a READ-DO checklist.
    • DO-CONFIRM checklist – team members perform tasks from memory and then stop to review checklist to confirm everything was done that was supposed to be done.
    • READ-DO checklist – members carry out the tasks as they check them off
  • Length: Keep it between five and nine items (the limit of working memory), depends on how much time is available.
  • Content: Focus on “the killer items”- the steps that are most dangerous to skip but sometimes get forgotten.
  • Wording: should be simple and exact using the language familiar to the profession
  • The Look: Ideally should fit on one page, be free of clutter and unnecessary colors. Should use both uppercase and lowercase letters for ease of reading (and consider using a sans serif type like Helvetica)

Checklists must be tested in the real world before use; most first drafts require refining to do deal with unexpected complications. The book revisits the “Miracle on the Hudson”, when captain Sully Sullenberger landed the disabled US Airways jet in the Hudson River, highlighting the importance of checklists for the crew and the operational discipline to use them.

Checklists are NOT comprehensive how-to-guides. They are meant to be quick and simple tools aimed to bolster the skills of the expert practitioner (operator, technician, engineer).


The Checklist Manifesto: How to Get Things Right, Atul Gawande, Metropolitan Books, New York, 2009.

Tagged as:     Todd Stauffer     Human Error  

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