A Tech Review of The Checklist Manifesto: How to Get Things Right by Atul Gawande

This book really opened my eyes to the value of using checklists and coming from a techie background i wanted to do a review of the book with a technical slant. So this page is part book review part my own view and opinion. Its worth noting the book was published in 2011 so any statistic mentioned need to be reflected in that.

So What is a checklist?

We often use checklists in day to day use i.e baking a cake or making a shopping list  before we head of to Tesco's. Visually it has a line of items which we tick of when we are done

The definition from wikipedia is "checklist are a type of informational job aid used to reduce failure by compensating for potential limits of human memory and attention. It helps to ensure consistency and completeness in carrying out a task. A basic example is the "to do list." A more advanced checklist would be a schedule, which lays out tasks to be done according to time of day or other factors"


Around 500 years ago while checklists were i am sure  used to a degree  (i am guessing Christopher Columbus had a checklist of what was needed for his trip into the unknown from numbers of crew to amount of food, correct maps...)

In recent years with added complexity in many areas of our life checklists are really starting to show their value. The author of the book Atul Gawande has a medical background and a good part of the book covers the value of checklists in hospitals and the statistics really do prove how patient safety has been improved by the use of checklists.

The author takes you through a list of stories showing how using a checklist can be beneficial, while merging it with his own story of how to create a successful checklist.

As the stories develop you understand that while a Doctor or a Pilot is an expert in their field , Checklist (when used correctly) aid and support them in the work they do. It also talks of the battle to get checklist accepted especially in the healthcare industry.

A more binary checklists can just be followed such as in restaurants where you are using the checklist to make sure the food is identical every time it reaches a customer  or if documentation is needed such as in hospitals it can designed more to be a tick list item.

Checklists in healthcare

The book start by describing various scenarios where innocuous looking injuries encountered in A&E issues turned into serious issue very quickly because things were missed and overlooked. (an example of not following a checklist)

There are some standard checklist in hospitals such as checking the vital signs, where the following would be typically checked:

  • body temperature
  • pulse
  • blood pressure
  • respiratory rate

As healthcare has developed in the last 50 years complication has also increased.Studies show:

  •  30% of patients with strokes receive incomplete or inappropriate care from their doctors
  • as do 45 % of patients with Asthma
  • and 60% of patients with pneumonia.

It mentions the case of a 3 year old girl in Austria falling into a icy pond , she was lost beneath the surface for 30 mins. Because of a checklist the first res-ponders and the hospital telephone operator knew what their role was and through brilliant teamwork in the end they managed to get her heat beating again she made a full recovery. (they proved this was not a one off as they also saved a suicidal person froze in the snow and without a pulse & a lady trapped in a car in a river with cardiac and respiratory arrest in the following years)

Simple things in hospital such as infected central lines occur in 80,000 per year of people in the US and are fatal to between 5% and 28 % of time. In total in the USA there are 150,000 deaths following surgery every year. (more than 3 times the number of deaths from car crashes). in 2001 a Doctor at Johns Hopkins Hospital called Peter Pronovost introduced a basic hygiene checklist the results were so successful they calculated the checklist has prevented 43 infections and 88 deaths and saved 2 million dollars of costs over a year.

A large part of the book is dedicated to a safe surgery checklist which the author was introducing working alongside the WHO (World health organization). Worldwide after operations its estimated 7 million people are left disabled and 1 million dead. The checklist was aimed at being used globally in hospitals to improve patient safety. (which brought its own set of problems from local translations to different countries needing to edit the checklist to for their own needs). One aspects of the checklist that proved successful was simple introductions between members of staff before an operation some of whom had never worked together before.

Initially the checklist was misunderstood by the people carrying out the work and took to long so through trial and error they evolved the list into something which worked. (short and to the point while covering major key items, there were also key break points where the nurses/Doctors/anesthetists could stop and talk through what the operation was any potential complications i.e allergies). The result of the checklist in 8 hospitals out of 4,000 patients

  • major complications fell by 36%
  • Deaths fell by 47%
  • Using the checklist had saved an estimated 150 people from harm and 27 from death.
  • All Doctors using the checklist were asked "would you want the checklist to be used if you were having an operation" and 93% said yes.


The Final checklist

Checklists in other industries


On October 30th 1935 a new airplane the Boeing 299 was tested, it had so much complexity Major Hill and 1 other person died during the test flight. The complexity of this new airplane was to much for this very experience pilot. (https://www.thisdayinaviation.com/30-october-1935/). After this incident a group of test pilots came up with the novel idea of creating a checklist because flying this new plane was to complicated to be left to the memory of one person however expert.

Checklists in the airline industry are used as standard now through the evolution and understanding into crashes and near misses the checklist evolve.

For example US airways flight 1549 on the 14th January 2009 hit a swarm of Canadian geese and lost power to all their engines, the plane was flown by 2 pilots who had never worked together. 3 mins 29 seconds after the contact it was landing in the Hudson river (https://en.wikipedia.org/wiki/US_Airways_Flight_1549) in that time the pilot was searching for somewhere to land & the co-pilot was running through the engine failure checklists while also preparing the plane for ditching. To relight 1 engine typical took more than the 3mins of time they had so the co-pilot had to skip some steps and in the end he managed to restart 2 engines which investigator remarked as "very remarkable". In that time he also got the distress signal out and make sure the plane was properly configured for an emergency water landing.

155 lives were saved that day because of the actions of the 5 crew onboard.

A view from the airline industry "the power of checklists is limited, they can help experts remember how to manage complex process of configure a complex machine. They can make priorities clearer and prompt people to function better as a team, by themselves however checklists are above all, practical"

Here is an example of lack of teamwork having devasting consequences  https://en.wikipedia.org/wiki/Tenerife_airport_disaster

Its interesting to note airlines have a publication date on many of their checklist as they are expected to change with time.


The author talks about witnessing the use of checklists in one of this favorite local restaurants with the food very much cooked per a cooking checklist and another final check of any food going out by one of the 2 head chefs.

A slightly different example is in McDonald or Dominoes where they follow a predefined checklist of instruction to create your meal.

Investing and Fiance industry

Some people in the financial world have found checklist invaluable in the book their are examples of   “Value” Investors who buy shares in undervalued companies and use dispassionate analysis to choose stocks. Which allows them to remove human emotions and to stop repetition of mistakes.

Its not a formula to success but a check on human decisions.(remove gut feeling)

Checklists are also in regular everyday within the finance industry such as when opening a bank account to taking out a mortgage for example.



Building industry

Buildings are a lot more complicated today varying in size and shape compared to a typical building 100 years ago. But the building industry has evolved embracing the change and in the use of checklist making sure building are built safely and to spec. A master builder no longer exists and instead its a team of experts in different areas that combine their knowledge and skill to create a building.

There is a great quote in the book "the biggest cause of serious error in the business is a failure of communication"

The building industry example from the book explains of 2 checklist 1 a basic checklist used to make sure obvious stupid things are not missed, and the second for more complex issues to allow people to talk and co-ordinate. With the idea that the wisdom of the group trumps an individual.

So for example, When an individual finds an issue, they need to have the ability to raise it to the effected teams have it added to a checklist  and confirm the issue was addressed.

And the approach obviously works according to a 2003 USA study "building failure" occur left than 0.00002% of the time.

Music industry

Checklists have been used in the music industry in a rather novel way , during a world tour Van Halen would send a contract to each venue due to host them with a checklist included buried deep in their was an item that a bowl of M&M's where provided with all the brown chocolates  removed.

When they turned up at a venue they could quickly see how thorough the venue had been in following their checklist based on the bowl of M&M's .If the item was missed they would line check the entire production. This approach found numerous vital safety items at venues which had been overlooked.

Civil Emergency

In 2005 when hurricane Katrina made landfall in New Orleans the general lack of co-ordination and communication became quickly apparent as the relief effort hit numerous issues.

Walmart were on the of the exceptions to the chaos taking the initiative and telling local managers

"A lot of you are going to have to make decisions above your level. Make the best decisions that you can with the information that's available to you at the time and above all do the right thing".

Using this approach (combined with their pre planning) there were able to supply water and food to refuges and even to the national guard a day before the government appeared on the scene.  Another example in the book refers to a Walmart manger breaking into their own store to collect medications for use at the local hospital.

The real lesson from this are that is really an anti checklist lesson whereby very complex conditions are hard to plan for and sometimes people just need to act and adapt. Saying that communication is also vital and should not be overlooked.

Advantages of checklists

  • Defend the most experienced against failure
  • Good for doing repetitive tasks they stop people getting complacent and missing things.
  • The human brain and memory is fallible. Checklists establish a higher standard of baseline performance.
  • In complex lines of work  they are not comprehensive how to guides weather for building a sky scraper of flying a plane , they are quick and simple tools to support the skills of an expert professional.

Disadvantages of checklists

if they are introduced in an ineffective way they can be time consuming , cumbersome and unproductive. Checklists cannot be used everywhere.

What should checklists be and not be?

Good checklists

  • Good checklists are precise, efficient, to the point, and easy to use in difficult situations, try not to spell everything out, a reminder of the most critical and important steps
  • Should be quick and simple tools to support experts
  • Drop minor items which only say occur with a frequency of 0.001% percent
  • Checklists when well made gets the dumb stuff out of the way so you can concentrate on the complicated stuff

When checklist shouldn't be used

  • Not all situations need checklists the key is identifying when (raising a child for example is complex and a checklist would not necessarily work)
  • The more Unpredictable the hard it is to create an effective checklist
  • Bad checklists are vague and imprecise, long, hard to use and impractical, made by people without understanding of real life knowledge, are long (between 5 and 9 items are about right)

Getting it to work

  • Make it simple and relevant, over complication puts everyone off
  • A checklist needs buy in and its best not to be forced upon people
  • Continually evolve your checklist so you learn from your problems
  • A checklist needs to be tested in the real world, it needs to be tweaked and modified until it works consistently, if an item is done 100% of the time example log on to a pod there is no point including it in the checklist
  • Are you doing it for record keeping if so you need tickets rather than say verbal acceptance.
  • If the checklist is going to be used globally across multiple teams a lot of trial and error (& research) need to be done to make sure its appropriate for everyone. Each team also need to have flexibility to adjust (wording ,order & additions)the list accordingly.
  • Should not hinder but help, its only an aid and if it doesn’t aid its not right
  • Anything that’s to complicated to checklist should result in a chat between parties (to reach consensus and understanding)

What can the Tech industry learn from checklists?

We may already use variants of checklists without realizing it, SOP (Standard operating procedures), DR procedures, weekly and monthly "to-do" lists,recruitment,new starters checklists.scripts to name a few.While the technical industry isn't on the whole life and death in the same way Airlines and healthcare are they can still be massive repercussions of the work we do.  (i am sure there are lots of exceptions here)

We may not "need" checklists to the same extent as other industries , but its interesting to see 2 industries really embracing checklists (Airlines and Builders) versus the healthcare industry which seems to be dragging its feet (which is described in further detail in the book) . I feel its also going to be harder to prove the success of checklists in IT.

I think the real take away from the book apart from the use of checklists though is the importance off communication there have been psychology studies in various fields of people who didn't know each others names not working nearly as well together as those who do. During research in the book after a number of hospital operations over 50% over the time staff didn't know each others names.

Knowing each others names  seemed to activate the sense of participation and responsibility and their willingness to speak up. There was also a strong correlation between communication ,results, staff retention and employee satisfaction.

Maybe in the tech world we need to take our headphones off occasionally , speak to our colleagues more and during lunch breaks and do anything else that improves communication (in an industry where we can be anti-social)