checklists can save lives

#41 – The Checklist Manifesto: How to Get Things Right by Atul Gawande

Dear Kafka,

Another great book.

4.5 stars on Amazon. 1,017 reviews. No mean feat.

why should you read it?

You will learn about using checklists to avoid failing unnecessarily.

Do you need to read a whole book just to learn that? Checklists are not new but how many people use them? This book is very persuasive and it made me think a lot about my own challenges and struggles to reach goals.

Along the way, you will learn more about the fields of medical care, construction and aviation. These aren’t sexy fields but the writing is good and made me very interested.

I will share an example from the book on how effective checklists are and explain why they are so.

a doctor checklist

Line infections are a common problem in intensive care.

“Line infections occur in eighty thousand people a year in the United States and are fatal between 5 and 28 percent of the time, depending on how sick one is at the start.”

In 2001, Dr Peter Pronovost developed a doctor checklist aimed at reducing line infections.

“On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting in a central line. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a mask, hat, sterile gown, and gloves, and (5) put a sterile dressing over the insertion site once the line is in. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist for something so obvious. Still, Pronovost asked the nurses in his ICU to observe the doctors for a month as they put lines into patients and record how often they carried out each step. In more than a third of patients, they skipped at least one.”

Even for a simple procedure, doctors miss important steps.

Dr Peter Pronovost persuaded his hospital to “authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask the doctors each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary.”


After the rule was implemented for a year, “the results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from 11 percent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths and saved two million dollars in costs.”

As the silly uncle in the stupid payWave ad likes to say, “so simple”.

why are checklists so effective?

The importance of Pause Points – because of checklists, surgeons have to pause before picking up the knife. Many of the mistakes I make are a result of not stopping before acting – hours ago, I was careless in my email and now have to write another email to explain what I wanted. I’ve been thinking a lot about introducing pause points in my life. For example, before eating, I should pause to be grateful and to remind myself to properly taste the food.

It facilitates communication – the checklists in the construction sector are very powerful tools to track progress and facilitate communication among the hundreds of companies working on a building.

Modern construction is very complex and involves multiple parties. The sector uses checklists to monitor daily construction tasks as well as make sure that the different parties are communicating with one another.

“There’s yet another program, called ProjectCenter, that allows anyone who has found a problem—even a frontline worker—to e-mail all the relevant parties, track progress, and make sure a check is added to the schedule to confirm that everyone has talked and resolved the matter… A worker had attached a digital photo of a twelve-foot steel I beam he was bolting in. It hadn’t lined up properly and only two of the four bolts could fit. Was that all right, the worker wanted to know? No, Rouillard wrote back. They worked out a solution together: to weld the beam into place. The e-mail was also automatically sent to the main contractor and anyone else who might potentially be required to sign off. Each party was given three days to confirm that the proposed solution was okay. And everyone needed to confirm they’d communicated, since the time taken for even this small fix could change the entire sequence in which other things needed to be done.”

According to an expert, “the major advance in the science of construction over the last few decades has been the perfection of tracking and communication.”

In surgery, research has shown that “team members are commonly not all aware of a given patient’s risks, or the problems they need to be ready for, or why the surgeon is doing the operation.”

Running the checklist ensures that everyone is on the same page and serious concerns are raised before an operation begins.

This has saved lives.

Checklists ensure that “killer steps” are not missed – these are the most critical steps not to be missed in any process. This made me think about the “killer steps” in the things I often do.

Checklists guard against human weaknesses – laziness, failure of memory, failure of attention, ego.

In fact, the biggest hurdle to using checklists is that people think it’s beneath them to use one.

Don’t be egoistic. Use checklists.

Mark Zuckerberg inspired me to start an annual personal project – read a non-fiction book every week and write about it. 

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