The life-saving power of a simple checklist
Last year, doctors at a Nairobi hospital performed surgery to remove a blood clot from a patient’s brain. Hours into the surgery, they came to a horrible realization: They were operating on the wrong guy, someone who had no need for an invasive medical procedure at all.
That’s the kind of awful scenario that the World Health Organization’s surgical safety checklist seeks to prevent. The checklist, the development of which was led by American surgeon, author, public-health researcher Atul Gawande in the mid-2000s, lays out 19 items for doctors and nurses to review over the course of three stages of surgery. The questions are extremely simple but potentially life-or-death in consequence, ranging from whether the patient has any known allergies to confirming the patient’s name and the scheduled procedure before a doctor makes the first incision.
Following these steps has been shown to cut down on human error. In the WHO’s initial pilot study of eight hospitals in eight international cities, for example, the checklist was associated with a one-third reduction in deaths and complications from surgery. Now a new study, published April 16 in the British Journal of Surgery, offers further reason to have faith in the transformative power of doing a straightforward, methodical, step-by-step review. Since Scotland implemented the checklist in 2008, surgery mortality rates have dropped by 37%, according to the study of 6.8 million surgical patients.
Gawande, who wrote the 2009 book The Checklist Manifesto, has been an outspoken advocate on behalf of the seemingly dull checklist. Central to his theory about its power is the idea that the lists act as a check on professional over-confidence. We tend to believe expertise, intelligence, and quick thinking are the essential skills we need to handle complex situations; what Gawande calls “expert audacity.” But as he explains in a 2007 article for The New Yorker, everyone messes up sometimes—and the more sophisticated an operation is, the more things there are that can go wrong. That’s why he wants doctors to embrace the “virtues of regimentation” rather than relying on intelligence and knowledge alone.
Checklists can save lives outside the hospital as well. In his New Yorker article, Gawande recounts how Boeing introduced the Model 299, a fancy new bomber with all kinds of capabilities, in 1935. The plane’s new features also made it more challenging to fly, which meant that the risk of pilot error went way up, as the US Army discovered during a tragic flight competition that led to the deaths of two crew members. In the aftermath of the crash, the Army introduced a checklist for pilots to review during takeoff, flight, landing, and taxiing. “With the checklist in hand, the pilots went on to fly the Model 299 a total of 1.8 million miles without one accident,” he explains.
The more stressful and important the situation, in fact, the more likely it is that we need a checklist to ensure we remember every detail and keep our cool. Apollo 11 crew member Michael Collins memorably called the astronauts’ extensive checklists their “fourth crewmember.” As Matthew Hersch wrote for Air & Space Magazine in 2009, the detailed instructions offered guidance on how to, among other things, “shut down the Lunar Module’s descent engine or exit from an inverted Command Module so as not to bump their heads (EXIT FEET FIRST).”
As Siddhartha Mukherjee noted in the New York Times (paywall) last year, the surgical checklists haven’t been shown to be successful across the board. In a 2014 study of 160,000 pregnant women in India, for example, the practice of reviewing a checklist had no impact on mortality rates for infants and mothers. Both the Times article and a 2015 Nature report by Emily Anthes suggest the implementation of the checklists, rather than the checklists themselves, may be a factor in studies with disappointing results; if medical teams treat them as perfunctory, believing they’re annoying and unnecessary, they’re more likely to skip over key steps.
So even if you’re not a doctor, a pilot, or an astronaut, there’s reason to think that following a checklist may help you reduce the chances of disaster the next time you or your team face a high-pressure situation—provided everyone takes the checklist seriously. One way to ensure everyone stays invested in a checklist, according to the Nature report? Let people tweak it according to their needs and work styles, rather than sticking rigidly to standardization. One doctor who introduced checklists into ICUs told Anthes that he’d encouraged each hospital to customize the checklist for their specific workplace. “They were 95% the same, but that 5% made it work for them,” he says. “Every one of these hospitals thought that theirs was the best.”
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