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Book review: The Checklist Manifesto: How to Get Things Right

Article  in  Journal of Nursing Management · October 2010

DOI: 10.1111/j.1365-2834.2010.01123.x

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Book review
The Checklist Manifesto. How
to get things right. Atul
Gawande, Profile Books,
London, UK. 2010, ISBN 0978
1846683138, 210 pp.
Imagine you are a pilot flying a
small aeroplane whose engine fails
in mid air. What would you do to
survive in the short time available?
Or imagine you are a pilot flying a
large passenger airliner and a cargo
hold door opens at 35 000 feet,
• a main plot: the development and
which risks depressurizing the whole
plane. How would you respond to
save plane and passengers? Panic?
• a sub-plot: the science behind the
Go into ostrich mode? For a less-
experienced pilot and team, these
responses are understandable and
• the hero(es): the clinical team
bring predictable consequences with
them. But, as the title of Atul Gaw-
• a ÔvillainÕ: the health professional
andeÕs book suggests, the best re-
sponse in both situations is to
perform a ÔREAD-DOÕ checklist.
An experienced surgeon and aca-
demic, Dr Gawande tells the story
behind the development of the
World Health Organisation (WHO)
Safe Surgical Checklist (Haynes
et al., 2009), drawing important
parallels between medicine and
other high-risk, high-reliability
industries such as construction,
finance and aviation. We learn that
these industries have managed to
distil the complexity of their tech-
niques into safer, more useable
forms and, mediated by the use of
checklists, achieve order-of-magni-
tude service improvements.
The original idea for the book
came from an informal and some-
what inevitable exchange of clinical
anecdotes when surgeons (or other
health professionals) meet and was
DOI: 10.1111/j.1365-2834.2010.01123.x
ª 2010 The Author. Journal compilation ª 2010 Blackwell Publishing Ltd
Journal of Nursing Management, 2010, 18, 619–620
also an extension of a New Yorker
article entitled: ÔThe Checklist
(Gawande 2007). Starting with a
clinical story about the emergency
care of a stabbed patient, which
neatly illustrates both the pressures
and complexity of modern health
care when a life is at stake, the flow
of ideas in this book is progressive.
Building on his opening stanza, Dr
Gawande weaves a strong narrative
together using:
use of the abovementioned WHO
checklist;
checklist, and its use in other
industries;
working together; and
acting with hubris and too much
autonomy.
The book works on several levels.
First, there is something for the
general reader because, with its plot,
narrative and high medical drama, it
is not unlike an episode of ER.
However, unlike the characters in
ER, the key difference in this story is
that its heroes are those practitio-
ners who gel together in an emer-
gency and simply follow protocol.
Second, for the health professional
wanting to better understand pa-
tient safety, Dr Gawande shows that
in both routine and emergency sit-
uations, much professional auton-
omy must be sacrificed in order to
improve outcomes.
Enough industry comparators
and information are given (a list of
excellent, up-to-date references is
provided) to enable motivated pro-
fessionals develop insight into an
area of signal importance to the
future of health care. Finally, there
is also enough to intrigue the patient
safety expert, raise interesting
questions and progress the academic
debate.
In essence, the book provides a
coherent critique of the adverse
effects of unfettered professional
autonomy on clinical outcome and
the limits of human factors in imple-
mentation. More importantly, it
signposts its readers to a crucial part
of the remedy – the WHO Safe
Surgical Checklist – and chronicles its
development from origin to delivery.
Here it serves a very useful role.
But more than a checklist is nee-
ded. Without a Ôshared mental
modelÕ of events, no checklist can
ever work effectively, especially in a
medical emergency, if everyone
sings from a different hymn sheet.
Without Ôclosed-loop communica-
tionÕ, no practitioner truly knows
what is happening and without Ôsit-
uational awarenessÕ, potential haz-
ards cannot be nipped in the bud
before becoming serious or lethal.
Thus, we need to create systems
which enable health professionals to
work and communicate Ôon the
same pageÕ, in both normal situa-
tions and in extremis. By helping
readers understand this, the book
puts them well on the way to
becoming experts in patient safety.
So what about the moral of this
story? Recent events in aviation and
spaceflight are cleverly used to make
the point. In its earlier, pioneering
days, NASA recruited the best aero-
plane test pilots to become astro-
nauts developing the Mercury Space
619
Book review
programme. As epitomized in the
Tom Wolfe book The Right Stuff, it
took a special breed of nerve, skill
and expert audacity to consider fly-
ing an experimental aeroplane to the
fringes of space, and then to compete
with others to be the first astronaut
to fly there. Some died trying. To
Gawande, autonomous surgeons
are, by analogy, similar in outlook
and outcome.
This is contrasted with the recent
case of senior pilot Chesley ÔSullyÕ
Sullenberger. During an unprece-
dented double-engine bird strike
over the Hudson river, the plane
was successfully ditched in the river
with no loss of life and minimal
injury. Although a media in over-
drive were keen to portray him as
the sole hero bringing the plane
620 ª 2010 The Author. Journal compilation ª 2004 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 619–620
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down safely, he was always first to
pay tribute to a team following
procedure as being the root cause
of this safe outcome.
Readers are left to Ôgo figureÕ if
this team success was mediated by
the use of a checklist. The book
concludes with Dr Gawande finding
himself placed in a new doctorÕs
dilemma between using old-fash-
ioned surgical audacity or the
checklist he in part designed, to deal
with a serious surgical emergency.
I found this book entertaining,
easy to read, and making clear and
important points regarding the fu-
ture of safe health care delivery. It is
itself an essential ÔREAD-DOÕ for
anyone interested in improving
patient safety, and I strongly re-
commend it.
Dr DAVID NEWBOLD R N , P h D
Senior Lecturer in Health Services
Management,
University of East London,
London,
UK,
E-mail: d.a.newbold@uel.ac.uk
References
Gawande A. (2007) The Checklist. The
New Yorker. 10th December 2007.
Available at: http://www.newyorker.com/
reporting/2007/12/10/071210fa_fact_gaw
ande, accessed 13 June 2010.
Haynes A.B., Weiser T.G., Berry W.R.
et al. (2009) A Surgical Safety Check-
list to Reduce Morbidity and Mortality
in a Global Population. New England
Journal of Medicine 360 (5), 491–
499.