The checklist manifesto

Many industries today have entered complex phases where carrying out tasks relies not just on memory and expertise alone. As in aviation, integrating checklists into operations can instill discipline and higher performance. In high-pressure environments, human memory can falter amid pressing demands. It’s easy to overlook routine matters or convince yourself skipping steps rarely causes issues, though problems may slip through. Checklists protect against these difficulties. By making minimum necessary steps explicit and verifiable, checklists lead to more reliable outcomes.

Checklists take many formats - from forms people fill out themselves to timing charts or individualized care plans. Items can be “read and do,” confirming actions as specified, or “check once done,” verifying completion. Checklists are unlimited in application and can be developed for any situation.

Why do checklists work? They ensure people apply knowledge and expertise consistently through complex contexts. Furthermore, an emergent, self-reinforcing dynamic occurs. As more checklists develop and propagate, their quality improves. Many assume checklists only aid routine tasks, but they can excel in fluid situations.

When Hurricane Katrina hit New Orleans in 2005, communication infrastructure failed. A FEMA agent managed to helicopter over the flooding and stranded people, emailing an urgent report. However, the head of FEMA didn’t use email, so the agency only learned of the emergency a day later from news footage, after most of the city flooded. As local, state and federal governments debated responsibilities, conditions deteriorated.

The concept of using checklists to enhance safety and efficiency is not new, yet its application across various fields has shown remarkable results, underscoring the universal value of this simple tool. The World Health Organization's development of a 19-item Surgical Safety Checklist is a prime example of how a straightforward approach can lead to significant improvements in complex environments. This checklist, designed after thorough consultation, aims to reduce errors and adverse events while fostering teamwork during surgical procedures. It encompasses critical safety checks at three pivotal moments: before anesthesia is administered, before the first incision is made, and before the patient leaves the operating room. The implementation of this checklist has been associated with substantial reductions in morbidity and mortality, leading to its widespread adoption. However, the success of the checklist hinges on the surgical team's willingness to momentarily pause their routine workflows at these key moments, which requires a cultural shift towards valuing regimentation over the traditional culture of expert audacity.

The transformative power of checklists was also demonstrated in 2003 by critical care specialist Peter Pronovost at Johns Hopkins Hospital. Pronovost developed a simple checklist to prevent central line infections in intensive care units (ICUs). Despite the checklist's simplicity, it was observed that doctors often skipped steps in haste, leading to a significant risk of infection. With the hospital administration's support, nurses were empowered to intervene if a doctor missed a step, leading to a dramatic reduction in hospital line infections over the following 15 months. This not only prevented infections and saved lives but also resulted in substantial cost savings. Despite these impressive results, Pronovost faced challenges in promoting the adoption of checklists across other U.S. hospitals, highlighting the resistance to change within the medical community.