ALSO BY ATUL GAWANDE

BETTER: A SURGEON’S NOTES ON PERFORMANCE

COMPLICATIONS: A SURGEON’S NOTES ON AN IMPERFECT
SCIENCE



THE CHECKLIST MANIFESTO



ATUL GAWANDE



THE CHECKLIST MANIFESTO HOW TO GET THINGS
RIGHT



First published in Great Britain in 2010 by
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First published in America in 2009 by
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Copyright © Atul Gawande, 2010

Some material in this book originally appeared
in the New Yorker essay, ‘The Checklist’ in different form

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For Hunter, Hattie, and Walker



CONTENTS

INTRODUCTION

1. THE PROBLEM OF EXTREME COMPLEXITY
2. THE CHECKLIST
3. THE END OF THE MASTER BUILDER
4. THE IDEA
5. THE FIRST TRY
6. THE CHECKLIST FACTORY
7. THE TEST
8. THE HERO IN THE AGE OF CHECKLISTS
9. THE SAVE

NOTES ON SOURCES
ACKNOWLEDGMENTS



THE CHECKLIST MANIFESTO



INTRODUCTION

I was chatting with a medical school friend of mine who is now a
general surgeon in San Francisco. We were trading war stories, as surgeons
are apt to do. One of John’s was about a guy who came in on Halloween
night with a stab wound. He had been at a costume party. He got into an
altercation. And now here he was.

He was stable, breathing normally, not in pain, just drunk and babbling to
the trauma team. They cut off his clothes with shears and looked him over
from head to toe, front and back. He was of moderate size, about two
hundred pounds, most of the excess around his middle. That was where
they found the stab wound, a neat two-inch red slit in his belly, pouting
open like a fish mouth. A thin mustard yellow strip of omental fat tongued
out of it—fat from inside his abdomen, not the pale yellow, superficial fat
that lies beneath the skin. They’d need to take him to the operating room,
check to make sure the bowel wasn’t injured, and sew up the little gap.

“No big deal,” John said.
If it were a bad injury, they’d need to crash into the operating room—

stretcher flying, nurses racing to get the surgical equipment set up, the
anesthesiologists skipping their detailed review of the medical records. But
this was not a bad injury. They had time, they determined. The patient lay
waiting on his stretcher in the stucco-walled trauma bay while the OR was
readied.

Then a nurse noticed he’d stopped babbling. His heart rate had
skyrocketed. His eyes were rolling back in his head. He didn’t respond
when she shook him. She called for help, and the members of the trauma
team swarmed back into the room. His blood pressure was barely detectible.
They stuck a tube down his airway and pushed air into his lungs, poured
fluid and emergency-release blood into him. Still they couldn’t get his
pressure up.



So now they were crashing into the operating room—stretcher flying,
nurses racing to get the surgical equipment set up, the anesthesiologists
skipping their review of the records, a resident splashing a whole bottle of
Betadine antiseptic onto his belly, John grabbing a fat No. 10 blade and
slicing down through the skin of the man’s abdomen in one clean,
determined swipe from rib cage to pubis.

“Cautery.”
He drew the electrified metal tip of the cautery pen along the fat

underneath the skin, parting it in a line from top to bottom, then through the
fibrous white sheath of fascia between the abdominal muscles. He pierced
his way into the abdominal cavity itself, and suddenly an ocean of blood
burst out of the patient.

“Crap.”
The blood was everywhere. The assailant’s knife had gone more than a

foot through the man’s skin, through the fat, through the muscle, past the
intestine, along the left of his spinal column, and right into the aorta, the
main artery from the heart.

“Which was crazy,” John said. Another surgeon joined to help and got a
fist down on the aorta, above the puncture point. That stopped the worst of
the bleeding and they began to get control of the situation. John’s colleague
said he hadn’t seen an injury like it since Vietnam.

The description was pretty close, it turned out. The other guy at the
costume party, John later learned, was dressed as a soldier—with a bayonet.

The patient was touch and go for a couple days. But he pulled through.
John still shakes his head ruefully when he talks about the case.

There are a thousand ways that things can go wrong when you’ve got a
patient with a stab wound. But everyone involved got almost every step
right—the head-to-toe examination, the careful tracking of the patient’s
blood pressure and pulse and rate of breathing, the monitoring of his
consciousness, the fluids run in by IV, the call to the blood bank to have
blood ready, the placement of a urinary catheter to make sure his urine was
running clear, everything. Except no one remembered to ask the patient or
the emergency medical technicians what the weapon was.

“Your mind doesn’t think of a bayonet in San Francisco,” John could
only say.



He told me about another patient, who was undergoing an operation to
remove a cancer of his stomach when his heart suddenly stopped.* John
remembered looking up at the cardiac monitor and saying to the
anesthesiologist, “Hey, is that asystole?” Asystole is total cessation of heart
function. It looks like a flat line on the monitor, as if the monitor is not even
hooked up to the patient.

The anesthesiologist said, “A lead must have fallen off,” because it
seemed impossible to believe that the patient’s heart had stopped. The man
was in his late forties and had been perfectly healthy. The tumor was found
almost by chance. He had gone to see his physician about something else, a
cough perhaps, and mentioned he’d been having some heartburn, too. Well,
not heartburn exactly. He felt like food sometimes got stuck in his
esophagus and wouldn’t go down and that gave him heartburn. The doctor
ordered an imaging test that required him to swallow a milky barium drink
while standing in front of an X-ray machine. And there on the images it
was: a fleshy mouse-size mass, near the top of the stomach, intermittently
pressing up against the entrance like a stopper. It had been caught early.
There were no signs of spread. The only known cure was surgery, in this
case a total gastrectomy, meaning removal of his entire stomach, a major
four-hour undertaking.

The team members were halfway through the procedure. The cancer was
out. There’d been no problems whatsoever. They were getting ready to
reconstruct the patient’s digestive tract when the monitor went flat-line. It
took them about five seconds to figure out that a lead had not fallen off. The
anesthesiologist could feel no pulse in the patient’s carotid artery. His heart
had stopped.

John tore the sterile drapes off the patient and started doing chest
compressions, the patient’s intestines bulging in and out of his open
abdomen with each push. A nurse called a Code Blue.

John paused here in telling the story and asked me to suppose I was in his
situation. “So, now, what would you do?”

I tried to think it through. The asystole happened in the midst of major
surgery. Therefore, massive blood loss would be at the top of my list. I
would open fluids wide, I said, and look for bleeding.

That’s what the anesthesiologist said, too. But John had the patient’s
abdomen completely open. There was no bleeding, and he told the



anesthesiologist so.
“He couldn’t believe it,” John said. “He kept saying, ‘There must be

massive bleeding! There must be massive bleeding!’ ” But there was none.
Lack of oxygen was also a possibility. I said I’d put the oxygen at 100

percent and check the airway. I’d also draw blood and send it for stat
laboratory tests to rule out unusual abnormalities.

John said they thought of that, too. The airway was fine. And as for the
lab tests, they would take at least twenty minutes to get results, by which
point it would be too late.

Could it be a collapsed lung—a pneumothorax? There were no signs of it.
They listened with a stethoscope and heard good air movement on both
sides of the chest.

The cause therefore had to be a pulmonary embolism, I said—a blood
clot must have traveled to the patient’s heart and plugged off his circulation.
It’s rare, but patients with cancer undergoing major surgery are at risk, and
if it happens there’s not much that can be done. One could give a bolus of
epinephrine— adrenalin—to try to jump-start the heart, but it wouldn’t
likely do much good.

John said that his team had come to the same conclusion. After fifteen
minutes of pumping up and down on the patient’s chest, the line on the
screen still flat as death, the situation seemed hopeless. Among those who
arrived to help, however, was a senior anesthesiologist who had been in the
room when the patient was being put to sleep. When he left, nothing
seemed remotely off-kilter. He kept thinking to himself, someone must have
done something wrong.

He asked the anesthesiologist in the room if he had done anything
different in the fifteen minutes before the cardiac arrest.

No. Wait. Yes. The patient had had a low potassium level on routine labs
that were sent during the first part of the case, when all otherwise seemed
fine, and the anesthesiologist had given him a dose of potassium to correct
it.

I was chagrined at having missed this possibility. An abnormal level of
potassium is a classic cause of asystole. It’s mentioned in every textbook. I
couldn’t believe I overlooked it. Severely low potassium levels can stop the
heart, in which case a corrective dose of potassium is the remedy. And too



much potassium can stop the heart, as well—that’s how states execute
prisoners.

The senior anesthesiologist asked to see the potassium bag that had been
hanging. Someone fished it out of the trash and that was when they figured
it out. The anesthesiologist had used the wrong concentration of potassium,
a concentration one hundred times higher than he’d intended. He had, in
other words, given the patient a lethal overdose of potassium.

After so much time, it wasn’t clear whether the patient could be revived.
It might well have been too late. But from that point on, they did everything
they were supposed to do. They gave injections of insulin and glucose to
lower the toxic potassium level. Knowing that the medications would take a
good fifteen minutes to kick in—way too long—they also gave intravenous
calcium and inhaled doses of a drug called albuterol, which act more
quickly. The potassium levels dropped rapidly. And the patient’s heartbeat
did indeed come back.

The surgical team was so shaken they weren’t sure they could finish the
operation. They’d not only nearly killed the man but also failed to recognize
how. They did finish the procedure, though. John went out and told the
family what had happened. He and the patient were lucky. The man
recovered—almost as if the whole episode had never occurred.

The stories surgeons tell one another are often about the shock of the
unexpected—the bayonet in San Francisco, the cardiac arrest when all
seemed fine—and sometimes about regret over missed possibilities. We talk
about our great saves but also about our great failures, and we all have
them. They are part of what we do. We like to think of ourselves as in
control. But John’s stories got me thinking about what is really in our
control and what is not.

In the 1970s, the philosophers Samuel Gorovitz and Alasdair MacIntyre
published a short essay on the nature of human fallibility that I read during
my surgical training and haven’t stopped pondering since. The question
they sought to answer was why we fail at what we set out to do in the
world. One reason, they observed, is “necessary fallibility”—some things
we want to do are simply beyond our capacity. We are not omniscient or all-
powerful. Even enhanced by technology, our physical and mental powers



are limited. Much of the world and universe is—and will remain—outside
our understanding and control.

There are substantial realms, however, in which control is within our
reach. We can build skyscrapers, predict snowstorms, save people from
heart attacks and stab wounds. In such realms, Gorovitz and MacIntyre
point out, we have just two reasons that we may nonetheless fail.

The first is ignorance—we may err because science has given us only a
partial understanding of the world and how it works. There are skyscrapers
we do not yet know how to build, snowstorms we cannot predict, heart
attacks we still haven’t learned how to stop. The second type of failure the
philosophers call ineptitude—because in these instances the knowledge
exists, yet we fail to apply it correctly. This is the skyscraper that is built
wrong and collapses, the snowstorm whose signs the meteorologist just
plain missed, the stab wound from a weapon the doctors forgot to ask about.

Thinking about John’s cases as a small sample of the difficulties we face
in early-twenty-first-century medicine, I was struck by how greatly the
balance of ignorance and ineptitude has shifted. For nearly all of history,
people’s lives have been governed primarily by ignorance. This was
nowhere more clear than with the illnesses that befell us. We knew little
about what caused them or what could be done to remedy them. But
sometime over the last several decades—and it is only over the last several
decades— science has filled in enough knowledge to make ineptitude as
much our struggle as ignorance.

Consider heart attacks. Even as recently as the 1950s, we had little idea
of how to prevent or treat them. We didn’t know, for example, about the
danger of high blood pressure, and had we been aware of it we wouldn’t
have known what to do about it. The first safe medication to treat
hypertension was not developed and conclusively demonstrated to prevent
disease until the 1960s. We didn’t know about the role of cholesterol, either,
or genetics or smoking or diabetes.

Furthermore, if someone had a heart attack, we had little idea of how to
treat it. We’d give some morphine for the pain, perhaps some oxygen, and
put the patient on strict bed rest for weeks—patients weren’t even permitted
to get up and go to the bathroom for fear of stressing their damaged hearts.
Then everyone would pray and cross their fingers and hope the patient



would make it out of the hospital to spend the rest of his or her life at home
as a cardiac cripple.

Today, by contrast, we have at least a dozen effective ways to reduce your
likelihood of having a heart attack—for instance, controlling your blood
pressure, prescribing a statin to lower cholesterol and inflammation,
limiting blood sugar levels, encouraging exercise regularly, helping with
smoking cessation, and, if there are early signs of heart disease, getting you
to a cardiologist for still further recommendations. If you should have a
heart attack, we have a whole panel of effective therapies that can not only
save your life but also limit the damage to your heart: we have clot-busting
drugs that can reopen your blocked coronary arteries; we have cardiac
catheters that can balloon them open; we have open heart surgery
techniques that let us bypass the obstructed vessels; and we’ve learned that
in some instances all we really have to do is send you to bed with some
oxygen, an aspirin, a statin, and blood pressure medications—in a couple
days you’ll generally be ready to go home and gradually back to your usual
life.

But now the problem we face is ineptitude, or maybe it’s “eptitude”—
making sure we apply the knowledge we have consistently and correctly.
Just making the right treatment choice among the many options for a heart
attack patient can be difficult, even for expert clinicians. Furthermore,
whatever the chosen treatment, each involves abundant complexities and
pitfalls. Careful studies have shown, for example, that heart attack patients
undergoing cardiac balloon therapy should have it done within ninety
minutes of arrival at a hospital. After that, survival falls off sharply. In
practical terms this means that, within ninety minutes, medical teams must
complete all their testing for every patient who turns up in an emergency
room with chest pain, make a correct diagnosis and plan, discuss the
decision with the patient, obtain his or her agreement to proceed, confirm
there are no allergies or medical problems that have to be accounted for,
ready a cath lab and team, transport the patient, and get started.

What is the likelihood that all this will actually occur within ninety
minutes in an average hospital? In 2006, it was less than 50 percent.

This is not an unusual example. These kinds of failures are routine in
medicine. Studies have found that at least 30 percent of patients with stroke
receive incomplete or inappropriate care from their doctors, as do 45



percent of patients with asthma and 60 percent of patients with pneumonia.
Getting the steps right is proving brutally hard, even if you know them.

I have been trying for some time to understand the source of our greatest
difficulties and stresses in medicine. It is not money or government or the
threat of malpractice lawsuits or insurance company hassles—although they
all play their role. It is the complexity that science has dropped upon us and
the enormous strains we are encountering in making good on its promise.
The problem is not uniquely American; I have seen it everywhere—in
Europe, in Asia, in rich countries and poor. Moreover, I have found to my
surprise that the challenge is not limited to medicine.

Know-how and sophistication have increased remarkably across almost
all our realms of endeavor, and as a result so has our struggle to deliver on
them. You see it in the frequent mistakes authorities make when hurricanes
or tornadoes or other disasters hit. You see it in the 36 percent increase
between 2004 and 2007 in lawsuits against attorneys for legal mistakes—
the most common being simple administrative errors, like missed calendar
dates and clerical screwups, as well as errors in applying the law. You see it
in flawed software design, in foreign intelligence failures, in our tottering
banks—in fact, in almost any endeavor requiring mastery of complexity and
of large amounts of knowledge.

Such failures carry an emotional valence that seems to cloud how we
think about them. Failures of ignorance we can forgive. If the knowledge of
the best thing to do in a given situation does not exist, we are happy to have
people simply make their best effort. But if the knowledge exists and is not
applied correctly, it is difficult not to be infuriated. What do you mean half
of heart attack patients don’t get their treatment on time? What do you
mean that two-thirds of death penalty cases are overturned because of
errors? It is not for nothing that the philosophers gave these failures so
unmerciful a name—ineptitude. Those on the receiving end use other
words, like negligence or even heartlessness.

For those who do the work, however—for those who care for the patients,
practice the law, respond when need calls—the judgment feels like it
ignores how extremely difficult the job is. Every day there is more and
more to manage and get right and learn. And defeat under conditions of
complexity occurs far more often despite great effort rather than from a lack



of it. That’s why the traditional solution in most professions has not been to
punish failure but instead to encourage more experience and training.

There can be no disputing the importance of experience. It is not enough
for a surgeon to have the textbook knowledge of how to treat trauma
victims—to understand the science of penetrating wounds, the damage they
cause, the different approaches to diagnosis and treatment, the importance
of acting quickly. One must also grasp the clinical reality, with its nuances
of timing and sequence. One needs practice to achieve mastery, a body of
experience before one achieves real success. And if what we are missing
when we fail is individual skill, then what is needed is simply more training
and practice.

But what is striking about John’s cases is that he is among the best-
trained surgeons I know, with more than a decade on the front lines. And
this is the common pattern. The capability of individuals is not proving to
be our primary difficulty, whether in medicine or elsewhere. Far from it.
Training in most fields is longer and more intense than ever. People spend
years of sixty, seventy-, eighty-hour weeks building their base of
knowledge and experience before going out into practice on their own—
whether they are doctors or professors or lawyers or engineers. They have
sought to perfect themselves. It is not clear how we could produce
substantially more expertise than we already have. Yet our failures remain
frequent. They persist despite remarkable individual ability.

Here, then, is our situation at the start of the twenty-first century: We have
accumulated stupendous know-how. We have put it in the hands of some of
the most highly trained, highly skilled, and hardworking people in our
society. And, with it, they have indeed accomplished extraordinary things.
Nonetheless, that know-how is often unmanageable. Avoidable failures are
common and persistent, not to mention demoralizing and frustrating, across
many fields—from medicine to finance, business to government. And the
reason is increasingly evident: the volume and complexity of what we know
has exceeded our individual ability to deliver its benefits correctly, safely,
or reliably. Knowledge has both saved us and burdened us.

That means we need a different strategy for overcoming failure, one that
builds on experience and takes advantage of the knowledge people have but
somehow also makes up for our inevitable human inadequacies. And there



is such a strategy— though it will seem almost ridiculous in its simplicity,
maybe even crazy to those of us who have spent years carefully developing
ever more advanced skills and technologies.

It is a checklist.



1. THE PROBLEM OF EXTREME COMPLEXITY

Some time ago I read a case report in the Annals of Thoracic Surgery. It
was, in the dry prose of a medical journal article, the story of a nightmare.
In a small Austrian town in the Alps, a mother and father had been out on a
walk in the woods with their three-year-old daughter. The parents lost sight
of the girl for a moment and that was all it took. She fell into an icy
fishpond. The parents frantically jumped in after her. But she was lost
beneath the surface for thirty minutes before they finally found her on the
pond bottom. They pulled her to the surface and got her to the shore.
Following instructions from an emergency response team reached on their
cell phone, they began cardiopulmonary resuscitation.

Rescue personnel arrived eight minutes later and took the first recordings
of the girl’s condition. She was unresponsive. She had no blood pressure or
pulse or sign of breathing. Her body temperature was just 66 degrees. Her
pupils were dilated and unreactive to light, indicating cessation of brain
function. She was gone.

But the emergency technicians continued CPR anyway. A helicopter took
her to the nearest hospital, where she was wheeled directly into an operating
room, a member of the emergency crew straddling her on the gurney,
pumping her chest. A surgical team got her onto a heart-lung bypass
machine as rapidly as it could. The surgeon had to cut down through the
skin of the child’s right groin and sew one of the desk-size machine’s
silicone rubber tubes into her femoral artery to take the blood out of her,
then another into her femoral vein to send the blood back. A perfusionist
turned the pump on, and as he adjusted the oxygen and temperature and
flow through the system, the clear tubing turned maroon with her blood.
Only then did they stop the girl’s chest compressions.

Between the transport time and the time it took to plug the machine into
her, she had been lifeless for an hour and a half. By the two-hour mark,



however, her body temperature had risen almost ten degrees, and her heart
began to beat. It was her first organ to come back.

After six hours, the girl’s core reached 98.6 degrees, normal body
temperature. The team tried to shift her from the bypass machine to a
mechanical ventilator, but the pond water and debris had damaged her lungs
too severely for the oxygen pumped in through the breathing tube to reach
her blood. So they switched her instead to an artificial-lung system known
as ECMO— extracorporeal membrane oxygenation. To do this, the
surgeons had to open her chest down the middle with a power saw and sew
the lines to and from the portable ECMO unit directly into her aorta and her
beating heart.

The ECMO machine now took over. The surgeons removed the heart-
lung bypass machine tubing. They repaired the vessels and closed her groin
incision. The surgical team moved the girl into intensive care, with her
chest still open and covered with sterile plastic foil. Through the day and
night, the intensive care unit team worked on suctioning the water and
debris from her lungs with a fiberoptic bronchoscope. By the next day, her
lungs had recovered sufficiently for the team to switch her from ECMO to a
mechanical ventilator, which required taking her back to the operating room
to unplug the tubing, repair the holes, and close her chest.

Over the next two days, all the girl’s organs recovered—her liver, her
kidneys, her intestines, everything except her brain. A CT scan showed
global brain swelling, which is a sign of diffuse damage, but no actual dead
zones. So the team escalated the care one step further. It drilled a hole into
the girl’s skull, threaded a probe into the brain to monitor the pressure, and
kept that pressure tightly controlled through constant adjustments in her
fluids and medications. For more than a week, she lay comatose. Then,
slowly, she came back to life.

First, her pupils started to react to light. Next, she began to breathe on her
own. And, one day, she simply awoke. Two weeks after her accident, she
went home. Her right leg and left arm were partially paralyzed. Her speech
was thick and slurry. But she underwent extensive outpatient therapy. By
age five, she had recovered her faculties completely. Physical and
neurological examinations were normal. She was like any little girl again.

What makes this recovery astounding isn’t just the idea that someone
could be brought back after two hours in a state that would once have been



considered death. It’s also the idea that a group of people in a random
hospital could manage to pull off something so enormously complicated.
Rescuing a drowning victimis nothing like it looks on television shows,
where a few chest compressions and some mouth-to-mouth resuscitation
always seem to bring someone with waterlogged lungs and a stilled heart
coughing and sputtering back to life. To save this one child, scores of
people had to carry out thousands of steps correctly: placing the heart-pump
tubing into her without letting in air bubbles; maintaining the sterility of her
lines, her open chest, the exposed fluid in her brain; keeping a
temperamental battery of machines up and running. The degree of difficulty
in any one of these steps is substantial. Then you must add the difficulties
of orchestrating them in the right sequence, with nothing dropped, leaving
some room for improvisation, but not too much.

For every drowned and pulseless child rescued, there are scores more
who don’t make it—and not just because their bodies are too far gone.
Machines break down; a team can’t get moving fast enough; someone fails
to wash his hands and an infection takes hold. Such cases don’t get written
up in the Annals of Thoracic Surgery, but they are the norm, though people
may not realize it.

I think we have been fooled about what we can expect from medicine—
fooled, one could say, by penicillin. Alexander Fleming’s 1928 discovery
held out a beguiling vision of health care and how it would treat illness or
injury in the future: a simple pill or injection would be capable of curing not
just one condition but perhaps many. Penicillin, after all, seemed to be
effective against an astonishing variety of previously untreatable infectious
diseases. So why not a similar cure-all for the different kinds of cancer?
And why not something equally simple to melt away skin burns or to
reverse cardiovascular disease and strokes?

Medicine didn’t turn out this way, though. After a century of incredible
discovery, most diseases have proved to be far more particular and difficult
to treat. This is true even for the infections doctors once treated with
penicillin: not all bacterial strains were susceptible and those that were soon
developed resistance. Infections today require highly individualized
treatment, sometimes with multiple therapies, based on a given strain’s
pattern of antibiotic susceptibility, the condition of the patient, and which
organ systems are affected. The model of medicine in the modern age seems



less and less like penicillin and more and more like what was required for
the girl who nearly drowned. Medicine has become the art of managing
extreme complexity—and a test of whether such complexity can, in fact, be
humanly mastered.

The ninth edition of the World Health Organization’s international
classification of diseases has grown to distinguish more than thirteen
thousand different diseases, syndromes, and types of injury—more than
thirteen thousand different ways, in other words, that the body can fail.
And, for nearly all of them, science has given us things we can do to help. If
we cannot cure the disease, then we can usually reduce the harm and misery
it causes. But for each condition the steps are different and they are almost
never simple. Clinicians now have at their disposal some six thousand drugs
and four thousand medical and surgical procedures, each with different
requirements, risks, and considerations. It is a lot to get right.

There is a community clinic in Boston’s Kenmore Square affiliated with
my hospital. The word clinic makes the place sound tiny, but it’s nothing of
the sort. Founded in 1969, and now called Harvard Vanguard, it aimed to
provide people with the full range of outpatient medical services they might
need over the course of their lives. It has since tried to stick with that plan,
but doing so hasn’t been easy. To keep up with the explosive growth in
medical capabilities, the clinic has had to build more than twenty facilities
and employ some six hundred doctors and a thousand other health
professionals covering fifty-nine specialties, many of which did not exist
when the clinic first opened. Walking the fifty steps from the fifth-floor
elevator to the general surgery department, I pass offices for general
internal medicine, endocrinology, genetics, hand surgery, laboratory testing,
nephrology, ophthalmology, orthopedics, radiology scheduling, and urology
—and that’s just one hallway.

To handle the complexity, we’ve split up the tasks among various
specialties. But even divvied up, the work can become overwhelming. In
the course of one day on general surgery call at the hospital, for instance,
the labor floor asked me to see a twenty-five-year-old woman with
mounting right lower abdominal pain, fever, and nausea, which raised
concern about appendicitis, but she was pregnant, so getting a CT scan to
rule out the possibility posed a risk to the fetus. A gynecological oncologist



paged me to the operating room about a woman with an ovarian mass that
upon removal appeared to be a metastasis from pancreatic cancer; my
colleague wanted me to examine her pancreas and decide whether to biopsy
it. A physician at a nearby hospital phoned me to transfer a patient in
intensive care with a large cancer that had grown to obstruct her kidneys
and bowel and produce bleeding that they were having trouble controlling.
Our internal medicine service called me to see a sixty-one-year-old man
with emphysema so severe he had been refused hip surgery because of
insufficient lung reserves; now he had a severe colon infection—an acute
diverticulitis—that had worsened despite three days of antibiotics, and
surgery seemed his only option. Another service asked for help with a fifty-
two-year-old man with diabetes, coronary artery disease, high blood
pressure, chronic kidney failure, severe obesity, a stroke, and now a
strangulating groin hernia. And an internist called about a young, otherwise
healthy woman with a possible rectal abscess to be lanced.

Confronted with cases of such variety and intricacy—in one day, I’d had
six patients with six completely different primary medical problems and a
total of twenty-six different additional diagnoses—it’s tempting to believe
that no one else’s job could be as complex as mine. But extreme complexity
is the rule for almost everyone. I asked the people in Harvard Vanguard’s
medical records department if they would query the electronic system for
how many different kinds of patient problems the average doctor there sees
annually. The answer that came back flabbergasted me. Over the course of a
year of office practice— which, by definition, excludes the patients seen in
the hospital— physicians each evaluated an average of 250 different
primary diseases and conditions. Their patients had more than nine hundred
other active medical problems that had to be taken into account. The
doctors each prescribed some three hundred medications, ordered more than
a hundred different types of laboratory tests, and performed an average of
forty different kinds of office procedures—from vaccinations to setting
fractures.

Even considering just the office work, the statistics still didn’t catch all
the diseases and conditions. One of the most common diagnoses, it turned
out, was “Other.” On a hectic day, when you’re running two hours behind
and the people in the waiting room are getting irate, you may not take the
time to record the precise diagnostic codes in the database. But, even when



you do have the time, you commonly find that the particular diseases your
patients have do not actually exist in the computer system.

The software used in most American electronic records has not managed
to include all the diseases that have been discovered and distinguished from
one another in recent years. I once saw a patient with a
ganglioneuroblastoma (a rare type of tumor of the adrenal gland) and
another with a nightmarish genetic condition called Li-Fraumeni syndrome,
which causes inheritors to develop cancers in organs all over their bodies.
Neither disease had yet made it into the pull-down menus. All I could
record was, in so many words, “Other.” Scientists continue to report
important new genetic findings, subtypes of cancer, and other diagnoses—
not to mention treatments—almost weekly. The complexity is increasing so
fast that even the computers cannot keep up.

But it’s not only the breadth and quantity of knowledge that has made
medicine complicated. It is also the execution—the practical matter of what
knowledge requires clinicians to do. The hospital is where you see just how
formidable the task can be. A prime example is the place the girl who
nearly drowned spent most of her recovery—the intensive care unit.

It’s an opaque term, intensive care. Specialists in the field prefer to call
what they do critical care, but that still doesn’t exactly clarify matters. The
nonmedical term life support gets us closer. The damage that the human
body can survive these days is as awesome as it is horrible: crushing,
burning, bombing, a burst aorta, a ruptured colon, a massive heart attack,
rampaging infection. These maladies were once uniformly fatal. Now
survival is commonplace, and a substantial part of the credit goes to the
abilities intensive care units have developed to take artificial control of
failing bodies. Typically, this requires a panoply of technology— a
mechanical ventilator and perhaps a tracheostomy tube if the lungs have
failed, an aortic balloon pump if the heart has given out, a dialysis machine
if the kidneys don’t work. If you are unconscious and can’t eat, silicone
tubing can be surgically inserted into your stomach or intestines for formula
feeding. If your intestines are too damaged, solutions of amino acids, fatty
acids, and glucose can be infused directly into your bloodstream.

On any given day in the United States alone, some ninety thousand
people are admitted to intensive care. Over a year, an estimated five million
Americans will be, and over a normal lifetime nearly all of us will come to



know the glassed bay of an ICU from the inside. Wide swaths of medicine
now depend on the life support systems that ICUs provide: care for
premature infants; for victims of trauma, strokes, and heart attacks; for
patients who have had surgery on their brains, hearts, lungs, or major blood
vessels. Critical care has become an increasingly large portion of what
hospitals do. Fifty years ago, ICUs barely existed. Now, to take a recent
random day in my hospital, 155 of our almost 700 patients are in intensive
care. The average stay of an ICU patient is four days, and the survival rate
is 86 percent. Going into an ICU, being put on a mechanical ventilator,
having tubes and wires run into and out of you, is not a sentence of death.
But the days will be the most precarious of your life.

Fifteen years ago, Israeli scientists published a study in which engineers
observed patient care in ICUs for twenty-four-hour stretches. They found
that the average patient required 178 individual actions per day, ranging
from administering a drug to suctioning the lungs, and every one of them
posed risks. Remarkably, the nurses and doctors were observed to make an
error in just 1 percent of these actions—but that still amounted to an
average of two errors a day with every patient. Intensive care succeeds only
when we hold the odds of doing harm low enough for the odds of doing
good to prevail. This is hard. There are dangers simply in lying unconscious
in bed for a few days. Muscles atrophy. Bones lose mass. Pressure ulcers
form. Veins begin to clot. You have to stretch and exercise patients’ flaccid
limbs daily to avoid contractures; you have to give subcutaneous injections
of blood thinners at least twice a day, turn patients in bed every few hours,
bathe them and change their sheets without knocking out a tube or a line,
brush their teeth twice a day to avoid pneumonia from bacterial buildup in
their mouths. Add a ventilator, dialysis, and the care of open wounds, and
the difficulties only accumulate.

The story of one of my patients makes the point. Anthony DeFilippo was
a forty-eight-year-old limousine driver from Everett, Massachusetts, who
started to hemorrhage at a community hospital during surgery for a hernia
and gallstones. The surgeon was finally able to stop the bleeding but
DeFilippo’s liver was severely damaged, and over the next few days he
became too sick for the hospital’s facilities. I accepted him for transfer in
order to stabilize him and figure out what to do. When he arrived in our
ICU, at 1:30 a.m. on a Sunday, his ragged black hair was plastered to his



sweaty forehead, his body was shaking, and his heart was racing at 114
beats a minute. He was delirious from fever, shock, and low oxygen levels.

“I need to get out!” he cried. “I need to get out!” He clawed at his gown,
his oxygen mask, the dressings covering his abdominal wound.

“Tony, it’s all right,” a nurse said to him. “We’re going to help you.
You’re in a hospital.”

He shoved her out of the way—he was a big man—and tried to swing his
legs out of the bed. We turned up his oxygen flow, put his wrists in cloth
restraints, and tried to reason with him. He eventually tired out and let us
draw blood and give him antibiotics.

The laboratory results came back showing liver failure and a steeply
elevated white blood cell count, indicating infection. It soon became
evident from his empty urine bag that his kidneys had failed, too. In the
next few hours, his blood pressure fell, his breathing worsened, and he
drifted from agitation to near unconsciousness. Each of his organ systems,
including his brain, was shutting down.

I called his sister, his next of kin, and told her the situation. “Do
everything you can,” she said.

So we did. We gave him a syringeful of anesthetic, and a resident slid a
breathing tube into his throat. Another resident “lined him up.” She inserted
a thin two-inch-long needle and catheter through his upturned right wrist
and into his radial artery, then sewed the line to his skin with a silk suture.
Next, she put in a central line—a twelve-inch catheter pushed into the
jugular vein in his left neck. After she sewed that in place, and an X-ray
showed its tip floating just where it was supposed to—inside his vena cava
at the entrance to his heart—she put a third, slightly thicker line, for
dialysis, through his right upper chest and into the subclavian vein, deep
under the collarbone.

We hooked a breathing tube up to a hose from a ventilator and set it to
give him fourteen forced breaths of 100 percent oxygen every minute. We
dialed the ventilator pressures and gas flow up and down, like engineers at a
control panel, until we got the blood levels of oxygen and carbon dioxide
where we wanted them. The arterial line gave us continuous arterial blood
pressure measurements, and we tweaked his medications to get the
pressures we liked. We regulated his intravenous fluids according to venous
pressure measurements from his jugular line. We plugged his subclavian



line into tubing from a dialysis machine, and every few minutes his entire
blood volume washed through this artificial kidney and back into his body;
a little adjustment here and there, and we could alter the levels of potassium
and bicarbonate and salt, as well. He was, we liked to imagine, a simple
machine in our hands.

But he wasn’t, of course. It was as if we had gained a steering wheel and
a few gauges and controls, but on a runaway 18-wheeler hurtling down a
mountain. Keeping that patient’s blood pressure normal required gallons of
intravenous fluid and a pharmacy shelf of drugs. He was on near-maximal
ventilator support. His temperature climbed to 104 degrees. Less than 5
percent of patients with DeFilippo’s degree of organ failure make it home.
A single misstep could easily erase those slender chances.

For ten days, though, we made progress. DeFilippo’s chief problem had
been liver damage from his prior operation: the main duct from his liver
was severed and was leaking bile, which is caustic—it digests the fat in
one’s diet and was essentially eating him alive from the inside. He had
become too sick to survive an operation to repair the leak. So once we had
stabilized him, we tried a temporary solution—we had radiologists place a
plastic drain, using CT guidance, through his abdominal wall and into the
severed duct in order to draw out the leaking bile. They found so much that
they had to place three drains—one inside the duct and two around it. But,
as the bile drained out, his fevers subsided. His need for oxygen and fluids
diminished, and his blood pressure returned to normal. He was beginning to
mend. Then, on the eleventh day, just as we were getting ready to take him
off the ventilator, he again developed high, spiking fevers, his blood
pressure sank, and his blood-oxygen levels plummeted again. His skin
became clammy. He got shaking chills.

We couldn’t understand what had happened. He seemed to have
developed an infection, but our X-rays and CT scans failed to turn up a
source. Even after we put him on four antibiotics, he continued to spike
fevers. During one fever, his heart went into fibrillation. A Code Blue was
called. A dozen nurses and doctors raced to his bedside, slapped electric
paddles onto his chest, and shocked him. His heart responded and went
back into rhythm. It took two more days for us to figure out what had gone
wrong. We considered the possibility that one of his lines had become
infected, so we put in new lines and sent the old ones to the lab for



culturing. Forty-eight hours later, the results returned. All the lines were
infected. The infection had probably started in one line, which perhaps was
contaminated during insertion, and spread through DeFilippo’s bloodstream
to the others. Then they all began spilling bacteria into him, producing the
fevers and steep decline.

This is the reality of intensive care: at any point, we are as apt to harm as
we are to heal. Line infections are so common that they are considered a
routine complication. ICUs put five million lines into patients each year,
and national statistics show that after ten days 4 percent of those lines
become infected. 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. Those who survive line infections
spend on average a week longer in intensive care. And this is just one of
many risks. After ten days with a urinary catheter, 4 percent of American
ICU patients develop a bladder infection. After ten days on a ventilator, 6
percent develop bacterial pneumonia, resulting in death 40 to 45 percent of
the time. All in all, about half of ICU patients end up experiencing a serious
complication, and once that occurs the chances of survival drop sharply.

It was another week before DeFilippo recovered sufficiently from his
infections to come off the ventilator and two months before he left the
hospital. Weak and debilitated, he lost his limousine business and his home,
and he had to move in with his sister. The tube draining bile still dangled
from his abdomen; when he was stronger, I was going to have to do surgery
to reconstruct the main bile duct from his liver. But he survived. Most
people in his situation do not.

Here, then, is the fundamental puzzle of modern medical care: you have a
desperately sick patient and in order to have a chance of saving him you
have to get the knowledge right and then you have to make sure that the 178
daily tasks that follow are done correctly—despite some monitor’s alarm
going off for God knows what reason, despite the patient in the next bed
crashing, despite a nurse poking his head around the curtain to ask whether
someone could help “get this lady’s chest open.” There is complexity upon
complexity. And even specialization has begun to seem inadequate. So what
do you do?



The medical profession’s answer has been to go from specialization to
superspecialization. I told DeFilippo’s ICU story, for instance, as if I were
the one tending to him hour by hour. That, however, was actually an
intensivist (as intensive care specialists like to be called). As a general
surgeon, I like to think I can handle most clinical situations. But, as the
intricacies involved in intensive care have grown, responsibility has
increasingly shifted to super-specialists. In the past decade, training
programs focusing on critical care have opened in most major American
and European cities, and half of American ICUs now rely on
superspecialists.

Expertise is the mantra of modern medicine. In the early twentieth
century, you needed only a high school diploma and a one-year medical
degree to practice medicine. By the century’s end, all doctors had to have a
college degree, a four-year medical degree, and an additional three to seven
years of residency training in an individual field of practice—pediatrics,
surgery, neurology, or the like. In recent years, though, even this level of
preparation has not been enough for the new complexity of medicine. After
their residencies, most young doctors today are going on to do fellowships,
adding one to three further years of training in, say, laparoscopic surgery, or
pediatric metabolic disorders, or breast radiology, or critical care. A young
doctor is not so young nowadays; you typically don’t start in independent
practice until your midthirties.

We live in the era of the superspecialist—of clinicians who have taken
the time to practice, practice, practice at one narrow thing until they can do
it better than anyone else. They have two advantages over ordinary
specialists: greater knowledge of the details that matter and a learned ability
to handle the complexities of the particular job. There are degrees of
complexity, though, and medicine and other fields like it have grown so far
beyond the usual kind that avoiding daily mistakes is proving impossible
even for our most superspecialized.

There is perhaps no field that has taken specialization further than
surgery. Think of the operating room as a particularly aggressive intensive
care unit. We have anesthesiologists just to handle pain control and patient
stability, and even they have divided into subcategories. There are pediatric
anesthesiologists, cardiac anesthesiologists, obstetric anesthesiologists,
neurosurgical anesthesiologists, and many others. Likewise, we no longer



have just “operating room nurses.” They too are often subspecialized for
specific kinds of cases.

Then of course there are the surgeons. Surgeons are so absurdly
ultraspecialized that when we joke about right ear surgeons and left ear
surgeons, we have to check to be sure they don’t exist. I am trained as a
general surgeon but, except in the most rural places, there is no such thing.
You really can’t do everything anymore. I decided to center my practice on
surgical oncology— cancer surgery—but even this proved too broad. So,
although I have done all I can to hang on to a broad span of general surgical
skills, especially for emergencies, I’ve developed a particular expertise in
removing cancers of endocrine glands.

The result of the recent decades of ever-refined specialization has been a
spectacular improvement in surgical capability and success. Where deaths
were once a double-digit risk of even small operations, and prolonged
recovery and disability was the norm, day surgery has become
commonplace.

Yet given how much surgery is now done—Americans today undergo an
average of seven operations in their lifetime, with surgeons performing
more than fifty million operations annually— the amount of harm remains
substantial. We continue to have upwards of 150,000 deaths following
surgery every year—more than three times the number of road traffic
fatalities. Moreover, research has consistently showed that at least half our
deaths and major complications are avoidable. The knowledge exists. But
however supremely specialized and trained we may have become, steps are
still missed. Mistakes are still made.

Medicine, with its dazzling successes but also frequent failures, therefore
poses a significant challenge: What do you do when expertise is not
enough? What do you do when even the super-specialists fail? We’ve begun
to see an answer, but it has come from an unexpected source—one that has
nothing to do with medicine at all.



2. THE CHECKLIST

On October 30, 1935, at Wright Air Field in Dayton, Ohio, the U.S.
Army Air Corps held a flight competition for airplane manufacturers vying
to build the military’s next-generation long-range bomber. It wasn’t
supposed to be much of a competition. In early evaluations, the Boeing
Corporation’s gleaming aluminum-alloy Model 299 had trounced the
designs of Martin and Douglas. Boeing’s plane could carry five times as
many bombs as the army had requested; it could fly faster than previous
bombers and almost twice as far. A Seattle newspaper man who had
glimpsed the plane on a test flight over his city called it the “flying
fortress,” and the name stuck. The flight “competition,” according to the
military historian Phillip Meilinger, was regarded as a mere formality. The
army planned to order at least sixty-five of the aircraft.

A small crowd of army brass and manufacturing executives watched as
the Model 299 test plane taxied onto the runway. It was sleek and
impressive, with a 103-foot wingspan and four engines jutting out from the
wings, rather than the usual two. The plane roared down the tarmac, lifted
off smoothly, and climbed sharply to three hundred feet. Then it stalled,
turned on one wing, and crashed in a fiery explosion. Two of the five crew
members died, including the pilot, Major Ployer P. Hill.

An investigation revealed that nothing mechanical had gone wrong. The
crash had been due to “pilot error,” the report said. Substantially more
complex than previous aircraft, the new plane required the pilot to attend to
the four engines, each with its own oil-fuel mix, the retractable landing
gear, the wing flaps, electric trim tabs that needed adjustment to maintain
stability at different airspeeds, and constant-speed propellers whose pitch
had to be regulated with hydraulic controls, among other features. While
doing all this, Hill had forgotten to release a new locking mechanism on the
elevator and rudder controls. The Boeing model was deemed, as a
newspaper put it, “too much airplane for one man to fly.” The army air



corps declared Douglas’s smaller design the winner. Boeing nearly went
bankrupt.

Still, the army purchased a few aircraft from Boeing as test planes, and
some insiders remained convinced that the aircraft was flyable. So a group
of test pilots got together and considered what to do.

What they decided not to do was almost as interesting as what they
actually did. They did not require Model 299 pilots to undergo longer
training. It was hard to imagine having more experience and expertise than
Major Hill, who had been the air corps’ chief of flight testing. Instead, they
came up with an ingeniously simple approach: they created a pilot’s
checklist. Its mere existence indicated how far aeronautics had advanced. In
the early years of flight, getting an aircraft into the air might have been
nerve-racking but it was hardly complex. Using a checklist for takeoff
would no more have occurred to a pilot than to a driver backing a car out of
the garage. But flying this new plane was too complicated to be left to the
memory of any one person, however expert.

The test pilots made their list simple, brief, and to the point— short
enough to fit on an index card, with step-by-step checks for takeoff, flight,
landing, and taxiing. It had the kind of stuff that all pilots know to do. They
check that the brakes are released, that the instruments are set, that the door
and windows are closed, that the elevator controls are unlocked—dumb
stuff. You wouldn’t think it would make that much difference. But with the
checklist in hand, the pilots went on to fly the Model 299 a total of 1.8
million miles without one accident. The army ultimately ordered almost
thirteen thousand of the aircraft, which it dubbed the B-17. And, because
flying the behemoth was now possible, the army gained a decisive air
advantage in the Second World War, enabling its devastating bombing
campaign across Nazi Germany.

Much of our work today has entered its own B-17 phase. Substantial
parts of what software designers, financial managers, firefighters, police
officers, lawyers, and most certainly clinicians do are now too complex for
them to carry out reliably from memory alone. Multiple fields, in other
words, have become too much airplane for one person to fly.

Yet it is far from obvious that something as simple as a checklist could be
of substantial help. We may admit that errors and oversights occur—even
devastating ones. But we believe our jobs are too complicated to reduce to a



checklist. Sick people, for instance, are phenomenally more various than
airplanes. A study of forty-one thousand trauma patients in the state of
Pennsylvania—just trauma patients—found that they had 1,224 different
injury-related diagnoses in 32,261 unique combinations. That’s like having
32,261 kinds of airplane to land. Mapping out the proper steps for every
case is not possible, and physicians have been skeptical that a piece of
paper with a bunch of little boxes would improve matters.

But we have had glimmers that it might, at least in some corners. What,
for instance, are the vital signs that every hospital records if not a kind of
checklist? Comprised of four physiological data points—body temperature,
pulse, blood pressure, and respiratory rate—they give health professionals a
basic picture of how sick a person is. Missing one of these measures can be
dangerous, we’ve learned. Maybe three of them seem normal—the patient
looks good, actually—and you’re inclined to say, “Eh, she’s fine, send her
home.” But perhaps the fourth reveals a fever or low blood pressure or a
galloping heart rate, and skipping it could cost a person her life.

Practitioners have had the means to measure vital signs since the early
twentieth century, after the mercury thermometer became commonplace and
the Russian physician Nicolai Korotkoff demonstrated how to use an
inflatable sleeve and stethoscope to quantify blood pressure. But although
using the four signs together as a group gauged the condition of patients
more accurately than using any of them singly, clinicians did not reliably
record them all.

In a complex environment, experts are up against two main difficulties.
The first is the fallibility of human memory and attention, especially when
it comes to mundane, routine matters that are easily overlooked under the
strain of more pressing events. (When you’ve got a patient throwing up and
an upset family member asking you what’s going on, it can be easy to forget
that you have not checked her pulse.) Faulty memory and distraction are a
particular danger in what engineers call all-or-none processes: whether
running to the store to buy ingredients for a cake, preparing an airplane for
takeoff, or evaluating a sick person in the hospital, if you miss just one key
thing, you might as well not have made the effort at all.

A further difficulty, just as insidious, is that people can lull themselves
into skipping steps even when they remember them. In complex processes,
after all, certain steps don’t always matter. Perhaps the elevator controls on



airplanes are usually unlocked and a check is pointless most of the time.
Perhaps measuring all four vital signs uncovers a worrisome issue in only
one out of fifty patients. “This has never been a problem before,” people
say. Until one day it is.

Checklists seem to provide protection against such failures. They remind
us of the minimum necessary steps and make them explicit. They not only
offer the possibility of verification but also instill a kind of discipline of
higher performance. Which is precisely what happened with vital signs—
though it was not doctors who deserved the credit.

The routine recording of the four vital signs did not become the norm in
Western hospitals until the 1960s, when nurses embraced the idea. They
designed their patient charts and forms to include the signs, essentially
creating a checklist for themselves.

With all the things nurses had to do for their patients over the course of a
day or night—dispense their medications, dress their wounds, troubleshoot
problems—the “vitals chart” provided a way of ensuring that every six
hours, or more often when nurses judged necessary, they didn’t forget to
check their patient’s pulse, blood pressure, temperature, and respiration and
assess exactly how the patient was doing.

In most hospitals, nurses have since added a fifth vital sign: pain, as rated
by patients on a scale of one to ten. And nurses have developed yet further
such bedside innovations—for example, medication timing charts and brief
written care plans for every patient. No one calls these checklists but, really,
that’s what they are. They have been welcomed by nursing but haven’t quite
carried over into doctoring.

Charts and checklists, that’s nursing stuff—boring stuff. They are nothing
that we doctors, with our extra years of training and specialization, would
ever need or use.

In 2001, though, a critical care specialist at Johns Hopkins Hospital named
Peter Pronovost decided to give a doctor checklist a try. He didn’t attempt
to make the checklist encompass everything ICU teams might need to do in
a day. He designed it to tackle just one of their hundreds of potential tasks,
the one that nearly killed Anthony DeFilippo: central 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.

The next month, he and his team persuaded the Johns Hopkins Hospital
administration 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. Nurses have always had their ways of
nudging a doctor into doing the right thing, ranging from the gentle
reminder (“Um, did you forget to put on your mask, doctor?”) to more
forceful methods (I’ve had a nurse bodycheck me when she thought I hadn’t
put enough drapes on a patient). But many nurses aren’t sure whether this is
their place or whether a given measure is worth a confrontation. (Does it
really matter whether a patient’s legs are draped for a line going into the
chest?) The new rule made it clear: if doctors didn’t follow every step, the
nurses would have backup from the administration to intervene.

For a year afterward, Pronovost and his colleagues monitored what
happened. 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.

Pronovost recruited more colleagues, and they tested some more
checklists in his Johns Hopkins ICU. One aimed to ensure that nurses
observed patients for pain at least once every four hours and provided
timely pain medication. This reduced from 41 percent to 3 percent the
likelihood of a patient’s enduring untreated pain. They tested a checklist for
patients on mechanical ventilation, making sure, for instance, that doctors
prescribed antacid medication to prevent stomach ulcers and that the head



of each patient’s bed was propped up at least thirty degrees to stop oral
secretions from going into the windpipe. The proportion of patients not
receiving the recommended care dropped from 70 percent to 4 percent, the
occurrence of pneumonias fell by a quarter, and twenty-one fewer patients
died than in the previous year. The researchers found that simply having the
doctors and nurses in the ICU create their own checklists for what they
thought should be done each day improved the consistency of care to the
point that the average length of patient stay in intensive care dropped by
half.

These checklists accomplished what checklists elsewhere have done,
Pronovost observed. They helped with memory recall and clearly set out the
minimum necessary steps in a process. He was surprised to discover how
often even experienced personnel failed to grasp the importance of certain
precautions. In a survey of ICU staff taken before introducing the ventilator
checklists, he found that half hadn’t realized that evidence strongly
supported giving ventilated patients antacid medication. Checklists, he
found, established a higher standard of baseline performance.

These seem, of course, ridiculously primitive insights.
Pronovost is routinely described by colleagues as “brilliant,” “inspiring,”

a “genius.” He has an M.D. and a Ph.D. in public health from Johns
Hopkins and is trained in emergency medicine, anesthesiology, and critical
care medicine. But, really, does it take all that to figure out what anyone
who has made a to-do list figured out ages ago? Well, maybe yes.

Despite his initial checklist results, takers were slow to come. He traveled
around the country showing his checklists to doctors, nurses, insurers,
employers—anyone who would listen. He spoke in an average of seven
cities a month. But few adopted the idea.

There were various reasons. Some physicians were offended by the
suggestion that they needed checklists. Others had legitimate doubts about
Pronovost’s evidence. So far, he’d shown only that checklists worked in one
hospital, Johns Hopkins, where the ICUs have money, plenty of staff, and
Peter Pronovost walking the hallways to make sure that the idea was being
properly implemented. How about in the real world—where ICU nurses and
doctors are in short supply, pressed for time, overwhelmed with patients,
and hardly receptive to the notion of filling out yet another piece of paper?



In 2003, however, the Michigan Health and Hospital Association
approached Pronovost about testing his central line checklist throughout the
state’s ICUs. It would be a huge undertaking. But Pronovost would have a
chance to establish whether his checklists could really work in the wider
world.

I visited Sinai-Grace Hospital, in inner-city Detroit, a few years after the
project was under way, and I saw what Pronovost was up against.
Occupying a campus of redbrick buildings amid abandoned houses, check-
cashing stores, and wig shops on the city’s West Side, just south of Eight
Mile Road, Sinai-Grace is a classic urban hospital. It employed at the time
eight hundred physicians, seven hundred nurses, and two thousand other
medical personnel to care for a population with the lowest median income
of any city in the country. More than a quarter of a million residents were
uninsured; 300,000 were on state assistance. That meant chronic financial
problems. Sinai-Grace is not the most cash-strapped hospital in the city—
that would be Detroit Receiving Hospital, where more than a fifth of the
patients have no means of payment. But between 2000 and 2003, Sinai-
Grace and eight other Detroit hospitals were forced to cut a third of their
staff, and the state had to come forward with a $50 million bailout to avert
their bankruptcy.

Sinai-Grace has five ICUs for adult patients and one for infants. Hassan
Makki, the director of intensive care, told me what it was like there in 2004,
when Pronovost and the hospital association started a series of mailings and
conference calls with hospitals to introduce checklists for central lines and
ventilator patients. “Morale was low,” he said. “We had lost lots of staff,
and the nurses who remained weren’t sure if they were staying.” Many
doctors were thinking about leaving, too. Meanwhile, the teams faced an
even heavier workload because of new rules limiting how long the residents
could work at a stretch. Now Pronovost was telling them to find the time to
fill out some daily checklists? Tom Piskorowski, one of the ICU physicians,
told me his reaction: “Forget the paperwork. Take care of the patient.”

I accompanied a team on 7:00 a.m. rounds through one of the surgical
ICUs. It had eleven patients. Four had gunshot wounds (one had been shot
in the chest; one had been shot through the bowel, kidney, and liver; two
had been shot through the neck and left quadriplegic). Five patients had
cerebral hemorrhaging (three were seventy-nine years and older and had



been injured falling down stairs; one was a middle-aged man whose skull
and left temporal lobe had been damaged by an assault with a blunt
weapon; and one was a worker who had become paralyzed from the neck
down after falling twenty-five feet off a ladder onto his head). There was a
cancer patient recovering from surgery to remove part of his lung, and a
patient who had had surgery to repair a cerebral aneurysm.

The doctors and nurses on rounds tried to proceed methodically from one
room to the next but were constantly interrupted: a patient they thought
they’d stabilized began hemorrhaging again; another who had been taken
off the ventilator developed trouble breathing and had to be put back on the
machine. It was hard to imagine that they could get their heads far enough
above the daily tide of disasters to worry about the minutiae on some
checklist.

Yet there they were, I discovered, filling out those pages. Mostly, it was
the nurses who kept things in order. Each morning, a senior nurse walked
through the unit, clipboard in hand, making sure that every patient on a
ventilator had the bed propped at the right angle and had been given the
right medicines and the right tests. Whenever doctors put in a central line, a
nurse made sure that the central line checklist had been filled out and placed
in the patient’s chart. Looking back through the hospital files, I found that
they had been doing this faithfully for more than three years.

Pronovost had been canny when he started. In his first conversations with
hospital administrators, he hadn’t ordered them to use the central line
checklist. Instead, he asked them simply to gather data on their own line
infection rates. In early 2004, they found, the infection rates for ICU
patients in Michigan hospitals were higher than the national average, and in
some hospitals dramatically so. Sinai-Grace experienced more central line
infections than 75 percent of American hospitals. Meanwhile, Blue Cross
Blue Shield of Michigan agreed to give hospitals small bonus payments for
participating in Pronovost’s program. A checklist suddenly seemed an easy
and logical thing to try.

In what became known as the Keystone Initiative, each hospital assigned
a project manager to roll out the checklist and participate in twice-monthly
conference calls with Pronovost for troubleshooting. Pronovost also insisted
that the participating hospitals assign to each unit a senior hospital



executive who would visit at least once a month, hear the staff ’s
complaints, and help them solve problems.

The executives were reluctant. They normally lived in meetings,
worrying about strategy and budgets. They weren’t used to venturing into
patient territory and didn’t feel they belonged there. In some places, they
encountered hostility, but their involvement proved crucial. In the first
month, the executives discovered that chlorhexidine soap, shown to reduce
line infections, was available in less than a third of the ICUs. This was a
problem only an executive could solve. Within weeks, every ICU in
Michigan had a supply of the soap. Teams also complained to the hospital
officials that, although the checklist required patients be fully covered with
a sterile drape when lines were being put in, full-size drapes were often
unavailable. So the officials made sure that drapes were stocked. Then they
persuaded Arrow International, one of the largest manufacturers of central
lines, to produce a new kit that had both the drape and chlorhexidine in it.

In December 2006, the Keystone Initiative published its findings in a
landmark article in the New England Journal of Medicine. Within the first
three months of the project, the central line infection rate in Michigan’s
ICUs decreased by 66 percent. Most ICUs—including the ones at Sinai-
Grace Hospital—cut their quarterly infection rate to zero. Michigan’s
infection rates fell so low that its average ICU outperformed 90 percent of
ICUs nationwide. In the Keystone Initiative’s first eighteen months, the
hospitals saved an estimated $175 million in costs and more than fifteen
hundred lives. The successes have been sustained for several years now—
all because of a stupid little checklist.

It is tempting to think this might be an isolated success. Perhaps there is
something unusual about the strategy required to prevent central line
infections. After all, the central line checklist did not prevent any of the
other kinds of complications that can result from sticking these foot-long
plastic catheters into people’s chests—such as a collapsed lung if the needle
goes in too deep or bleeding if a blood vessel gets torn. It just prevented
infections. In this particular instance, yes, doctors had some trouble getting
the basics right—making sure to wash their hands, put on their sterile
gloves and gown, and so on—and a checklist proved dramatically valuable.



But among the myriad tasks clinicians carry out for patients, maybe this is
the peculiar case.

I started to wonder, though.
Around the time I learned of Pronovost’s results, I spoke to Markus

Thalmann, the cardiac surgeon who had been the lead author of the case
report on the extraordinary rescue of the little girl from death by drowning.
Among the many details that intrigued me about the save was the fact that it
occurred not at a large cutting-edge academic medical center but at an
ordinary community hospital. This one was in Klagenfurt, a small
provincial Austrian town in the Alps nearest to where the girl had fallen in
the pond. I asked Thalmann how the hospital had managed such a
complicated rescue.

He told me he had been working in Klagenfurt for six years when the girl
came in. She had not been the first person whom he and his colleagues had
tried to revive from cardiac arrest after hypothermia and suffocation. His
hospital received between three and five such patients a year, he estimated,
mostly avalanche victims, some of them drowning victims, and a few of
them people attempting suicide by taking a drug overdose and then
wandering out into the snowy Alpine forests to fall unconscious. For a long
time, he said, no matter how hard the hospital’s medical staff tried, they had
no survivors. Most of the victims had been without a pulse and oxygen for
too long when they were found. But some, he was convinced, still had a
flicker of viability in them, yet he and his colleagues had always failed to
sustain it.

He took a close look at the case records. Preparation, he determined, was
the chief difficulty. Success required having an array of people and
equipment at the ready—trauma surgeons, a cardiac anesthesiologist, a
cardiothoracic surgeon, bioengineering support staff, a cardiac perfusionist,
operating and critical care nurses, intensivists. Almost routinely, someone
or something was missing.

He tried the usual surgical approach to remedy this—yelling at everyone
to get their act together. But still they had no saves.

So he and a couple of colleagues decided to try something new. They
made a checklist.

They gave the checklist to the people with the least power in the whole
process—the rescue squads and the hospital telephone operator—and



walked them through the details. In cases like these, the checklist said,
rescue teams were to tell the hospital to prepare for possible cardiac bypass
and rewarming. They were to call, when possible, even before they arrived
on the scene, as the preparation time could be significant. The telephone
operator would then work down a list of people to notify them to have
everything set up and standing by.

With the checklist in place, the team had its first success—the rescue of
the three-year-old girl. Not long afterward, Thalmann left to take a job at a
hospital in Vienna. The team, however, has since had at least two other such
rescues, he said. In one case, a man had been found frozen and pulseless
after a suicide attempt. In another, a mother and her sixteen-year-old
daughter were in an accident that sent them and their car through a
guardrail, over a cliff, and into a mountain river. The mother died on
impact; the daughter was trapped as the car rapidly filled with icy water.
She had been in cardiac and respiratory arrest for a prolonged period of
time when the rescue team arrived.

From that point onward, though, everything moved like clockwork. By
the time the rescue team got to her and began CPR, the hospital had been
notified. The transport team delivered her in minutes. The surgical team
took her straight to the operating room and crashed her onto heart-lung
bypass. One step followed right after another. And, because of the speed
with which they did, she had a chance.

As the girl’s body slowly rewarmed, her heart came back. In the ICU, a
mechanical ventilator, fluids, and intravenous drugs kept her going while
the rest of her body recovered. The next day, the doctors were able to
remove her lines and tubes. The day after that, she was sitting up in bed,
ready to go home.



3. THE END OF THE MASTER BUILDER

Four generations after the first aviation checklists went into use, a
lesson is emerging: checklists seem able to defend anyone, even the
experienced, against failure in many more tasks than we realized. They
provide a kind of cognitive net. They catch mental flaws inherent in all of
us—flaws of memory and attention and thoroughness. And because they
do, they raise wide, unexpected possibilities.

But they presumably have limits, as well. So a key step is to identify
which kinds of situations checklists can help with and which ones they
can’t.

Two professors who study the science of complexity— Brenda
Zimmerman of York University and Sholom Glouberman of the University
of Toronto—have proposed a distinction among three different kinds of
problems in the world: the simple, the complicated, and the complex.
Simple problems, they note, are ones like baking a cake from a mix. There
is a recipe. Sometimes there are a few basic techniques to learn. But once
these are mastered, following the recipe brings a high likelihood of success.

Complicated problems are ones like sending a rocket to the moon. They
can sometimes be broken down into a series of simple problems. But there
is no straightforward recipe. Success frequently requires multiple people,
often multiple teams, and specialized expertise. Unanticipated difficulties
are frequent. Timing and coordination become serious concerns.

Complex problems are ones like raising a child. Once you learn how to
send a rocket to the moon, you can repeat the process with other rockets and
perfect it. One rocket is like another rocket. But not so with raising a child,
the professors point out. Every child is unique. Although raising one child
may provide experience, it does not guarantee success with the next child.
Expertise is valuable but most certainly not sufficient. Indeed, the next child
may require an entirely different approach from the previous one. And this
brings up another feature of complex problems: their outcomes remain



highly uncertain. Yet we all know that it is possible to raise a child well. It’s
complex, that’s all.

Thinking about averting plane crashes in 1935, or stopping infections of
central lines in 2003, or rescuing drowning victims today, I realized that the
key problem in each instance was essentially a simple one, despite the
number of contributing factors. One needed only to focus attention on the
rudder and elevator controls in the first case, to maintain sterility in the
second, and to be prepared for cardiac bypass in the third. All were
amenable, as a result, to what engineers call “forcing functions”: relatively
straightforward solutions that force the necessary behavior— solutions like
checklists.

We are besieged by simple problems. In medicine, these are the failures
to don a mask when putting in a central line or to recall that one of the ten
causes of a flat-line cardiac arrest is a potassium overdose. In legal practice,
these are the failures to remember all the critical avenues of defense in a tax
fraud case or simply the various court deadlines. In police work, these are
the failures to conduct an eyewitness lineup properly, forgetting to tell the
witness that the perpetrator of the crime may not be in the lineup, for
instance, or having someone present who knows which one the suspect is.
Checklists can provide protection against such elementary errors.

Much of the most critical work people do, however, is not so simple.
Putting in a central line is just one of the 178 tasks an ICU team must
coordinate and execute in a day—ICU work is complicated—and are we
really going to be able to create and follow checklists for every possible one
of them? Is this even remotely practical? There is no straightforward recipe
for the care of ICU patients. It requires multiple practitioners orchestrating
different combinations of tasks for different conditions—matters that cannot
be controlled by simple forcing functions.

Plus, people are individual in ways that rockets are not—they are
complex. No two pneumonia patients are identical. Even with the same
bacteria, the same cough and shortness of breath, the same low oxygen
levels, the same antibiotic, one patient might get better and the other might
not. A doctor must be prepared for unpredictable turns that checklists seem
completely unsuited to address. Medicine contains the entire range of
problems—the simple, the complicated, and the complex—and there are



often times when a clinician has to just do what needs to be done. Forget the
paperwork. Take care of the patient.

I have been thinking about these matters for a long time now. I want to be
a good doctor for my patients. And the question of when to follow one’s
judgment and when to follow protocol is central to doing the job well—or
to doing anything else that is hard. You want people to make sure to get the
stupid stuff right. Yet you also want to leave room for craft and judgment
and the ability to respond to unexpected difficulties that arise along the way.
The value of checklists for simple problems seems self-evident. But can
they help avert failure when the problems combine everything from the
simple to the complex?

I happened across an answer in an unlikely place. I found it as I was just
strolling down the street one day.

It was a bright January morning in 2007. I was on my way to work,
walking along the sidewalk from the parking lot to the main entrance of my
hospital, when I came upon a new building under construction for our
medical center. It was only a skeleton of steel beams at that point, but it
stretched eleven stories high, occupied a full city block, and seemed to have
arisen almost overnight from the empty lot that had been there. I stood at
one corner watching a construction worker welding a joint as he balanced
on a girder four stories above me. And I wondered: How did he and all his
co-workers know that they were building this thing right? How could they
be sure that it wouldn’t fall down?

The building was not unusually large. It would provide 150 private
hospital beds (so we could turn our main tower’s old, mostly shared rooms
into private beds as well) and sixteen fancy new operating rooms (which I
was especially looking forward to)—nothing out of the ordinary. I would
bet that in the previous year dozens of bigger buildings had been
constructed around the country.

Still, this one was no small undertaking, as the hospital’s real estate
manager later told me. The building, he said, would be 350,000 square feet
in size, with three stories underground in addition to the eleven stories
above. It would cost $360 million, fully delivered, and require 3,885 tons of
steel, thirteen thousand yards of concrete, nineteen air handling units,
sixteen elevators, one cooling tower, and one backup emergency generator.



The construction workers would have to dig out 100,000 cubic yards of dirt
and install 64,000 feet of copper piping, forty-seven miles of conduit, and
ninety-five miles of electrical wire—enough to reach Maine.

And, oh yeah, I thought to myself, this thing couldn’t fall down.
When I was eleven years old, growing up in Athens, Ohio, I decided I

was going to build myself a bookcase. My mother gave me ten dollars, and
I biked down to the C&E Hardware store on Richland Avenue. With the
help of the nice man with hairy ears behind the counter, I bought four pine
planks, each eight inches wide and three-quarters of an inch thick and cut to
four feet long. I also bought a tin of stain, a tin of varnish, some sandpaper,
and a box of common nails. I lugged the stuff home to our garage. I
carefully measured my dimensions. Then I nailed the two cross planks into
the two side planks and stood my new bookcase up. It looked perfect. I
sanded down the surfaces, applied the stain and soon the varnish. I took it to
my bedroom and put a half dozen books on it. Then I watched the whole
thing fall sideways like a drunk tipping over. The two middle boards began
pulling out. So I hammered in a few more nails and stood the bookcase up
again. It tipped over the other way. I banged in some more nails, this time
coming in at an angle, thinking that would do the trick. It didn’t. Finally, I
just nailed the damn thing directly into the wall. And that was how I
discovered the concept of bracing.

So as I looked up at this whole building that had to stand up straight even
in an earthquake, puzzling over how the workers could be sure they were
constructing it properly, I realized the question had two components. First,
how could they be sure that they had the right knowledge in hand? Second,
how could they be sure that they were applying this knowledge correctly?

Both aspects are tricky. In designing a building, experts must take into
account a disconcertingly vast range of factors: the makeup of the local soil,
the desired height of the individual structure, the strength of the materials
available, and the geometry, to name just a few. Then, to turn the paper
plans into reality, they presumably face equally byzantine difficulties
making sure that all the different tradesmen and machinery do their job the
right way, in the right sequence, while also maintaining the flexibility to
adjust for unexpected difficulties and changes.

Yet builders clearly succeed. They safely put up millions of buildings all
over the globe. And they do so despite the fact that construction work has



grown infinitely more complex over the decades. Moreover, they do it with
a frontline workforce that regards each particular job—from pile-driving to
wiring intensive care units—much the way doctors, teachers, and other
professionals regard their jobs: as specialized domains in which others
should not interfere.

I paid a visit to Joe Salvia, the structural engineer for our new hospital
wing. I told him I wanted to find out how work is done in his profession. It
turned out I’d come to the right person. His firm, McNamara/Salvia, has
provided the structural engineering for most of the major hospital buildings
in Boston since the late 1960s, and for a considerable percentage of the
hotels, office towers, and condominiums as well. It did the structural
rebuilding of Fenway Park, the Boston Red Sox baseball team’s thirty-six-
thousand-seat stadium, including the Green Monster, its iconic thirty-seven-
foot, home-run-stealing left field wall. And the firm’s particular specialty
has been designing and engineering large, complicated, often high-rise
structures all over the country.

Salvia’s tallest skyscraper is an eighty-story tower going up in Miami. In
Providence, Rhode Island, his firm built a shopping mall that required one
of the largest steel mill orders placed on the East Coast (more than twenty-
four thousand tons); it is also involved in perhaps the biggest commercial
project in the world— the Meadowlands Xanadu entertainment and sports
complex in East Rutherford, New Jersey, which will house a stadium for the
New York Giants and New York Jets football teams, a three-thousand-seat
music theater, the country’s largest movie multiplex, and the SnowPark, the
nation’s first indoor ski resort. For most of the past several years,
McNamara/Salvia’s engineers have worked on fifty to sixty projects
annually, an average of one new building a week. And they have never had
a building come even close to collapsing.

So I asked Salvia at his office in downtown Boston how he has ensured
that the buildings he works on are designed and constructed right. Joe
Salvia is sixty-one, with almost no hair, a strong Boston accent, and a
cheery, take-your-time, how-about-some-coffee manner that I didn’t expect
from an engineer. He told me about the first project he ever designed—a
roof for a small shopping plaza.



He was just out of college, a twenty-three-year-old kid from East
Cambridge, which is not exactly where the Harvard professors live. His
father was a maintenance man and his mother worked in a meat processing
plant, but he was good in school and became the first member of his family
to go to college. He went to Tufts University planning to become a doctor.
Then he hit organic chemistry class.

“They said, ‘Here, we want you to memorize these formulas,’ ” he
explained. “I said, ‘Why do I have to memorize them if I know where the
book is?’ They said, ‘You want to be a doctor? That’s what you have to do
in medicine—you have to memorize everything.’ That seemed ridiculous to
me. Plus I wasn’t good at memorizing. So I quit.”

But Salvia was good at solving complex problems—he tried to explain
how he solves quadratic equations in his head, though all I managed to pick
up was that I’d never before heard someone say “quadratic equation” in a
Boston accent. “I also liked the concept of creating,” he said. As a result, he
switched to engineering, a scientific but practical field, and he loved it. He
learned, as he put it, “basic statics and dynamics—you know, F equals ma,”
and he learned about the chemistry and physics of steel, concretes, and soil.

But he’d built nothing when he graduated with his bachelor’s degree and
joined Sumner Shane, an architectural engineering firm that specialized in
structural engineering for shopping centers. One of its projects was a new
shopping mall in Texas, and Salvia was assigned the roof system. He found
he actually understood a lot about how to build a solid roof from his
textbooks and from the requirements detailed in building codes.

“I knew from college how to design with structural steel— how to use
beams and columns,” he said. And the local building codes spelled out what
was required for steel strength, soil composition, snow-bearing capacity,
wind-pressure resistance, and earthquake tolerance. All he had to do was
factor these elements into the business deal, which specified the size of the
building, the number of floors, the store locations, the loading docks. As we
talked he was already drawing the contours for me on a piece of paper. It
started out as a simple rectangle. Then he sketched in the store walls,
doorways, walking space. The design began taking form.

“You draw a grid of likely locations to carry the roof weight,” he said,
and he put in little crosses where columns could be placed. “The rest is
algebra,” he said. “You solve for X.” You calculate the weight of the roof



from its size and thickness, and then, given columns placed every thirty
feet, say, you calculate the diameter and strength of the column required.
You check your math to make sure you’ve met all the requirements.

All this he had learned in college. But, he discovered, there was more—
much more—that they hadn’t taught him in school.

“You know the geometric theory of what is best, but not the practical
theory of what can be done,” he said. There was the matter of cost, for
example, about which he had not a clue. The size and type of materials he
put in changed the cost of the project, it turned out. There was also the
matter of aesthetics, the desires of a client who didn’t want a column
standing in the middle of a floor, for instance, or blocking a particular
sightline.

“If engineers were in charge, every building would be a rectangular box,”
Salvia said. Instead, every building is new and individual in ways both
small and large—they are complex—and as a result there is often no
textbook formula for the problems that come up. Later, for example, when
he established his own firm, he and his team did the structural engineering
for Boston’s International Place, a landmark forty-six-story steel and glass
tower designed by the architect Philip Johnson. The building was unusual, a
cylinder smashed against a rectangle, a form that hadn’t been tried in a
skyscraper before. From a structural engineering point of view, Salvia
explained, cylinders are problematic. A square provides 60 percent more
stiffness than a circle, and in wind or an earthquake a building needs to be
able to resist the tendency to twist or bend. But a distorted cylinder it was,
and he and his team had to invent the engineering to realize Johnson’s
aesthetic vision.

Salvia’s first mall roof may have been a simpler proposition, but it
seemed to him at the time to have no end of difficulties. Besides the
concerns of costs and aesthetics, he also needed to deal with the
requirements of all the other professionals involved. There were the
plumbing engineers, the electrical engineers, the mechanical engineers—
every one of them wanting to put pipes, wiring, HVAC units just where his
support columns were supposed to go.

“A building is like a body,” he said. It has a skin. It has a skeleton. It has
a vascular system—the plumbing. It has a breathing system—the
ventilation. It has a nervous system—the wiring. All together, he explained,



projects today involve some sixteen different trades. He pulled out the
construction plans for a four-hundred-foot-tall skyscraper he was currently
building and flipped to the table of contents to show me. Each trade had
contributed its own separate section. There were sections for conveying
systems (elevators and escalators), mechanical systems (heating,
ventilation, plumbing, air conditioning, fire protection), masonry, concrete
structures, metal structures, electrical systems, doors and windows, thermal
and moisture systems (including waterproofing and insulation), rough and
finish carpentry, site work (including excavation, waste and storm water
collection, and walkways)—everything right down to the carpeting,
painting, landscaping, and rodent control.

All the separate contributions had to be included. Yet they also had to fit
together somehow so as to make sense as a whole. And then they had to be
executed precisely and in coordination. On the face of it, the complexities
seemed overwhelming. To manage them, Salvia said, the entire industry
was forced to evolve.

For most of modern history, he explained, going back to medieval times,
the dominant way people put up buildings was by going out and hiring
Master Builders who designed them, engineered them, and oversaw
construction from start to finish, portico to plumbing. Master Builders built
Notre Dame, St. Peter’s Basilica, and the United States Capitol building.
But by the middle of the twentieth century the Master Builders were dead
and gone. The variety and sophistication of advancements in every stage of
the construction process had overwhelmed the abilities of any individual to
master them.

In the first division of labor, architectural and engineering design split off
from construction. Then, piece by piece, each component became further
specialized and split off, until there were architects on one side, often with
their own areas of subspecialty, and engineers on another, with their various
kinds of expertise; the builders, too, fragmented into their own multiple
divisions, ranging from tower crane contractors to finish carpenters. The
field looked, in other words, a lot like medicine, with all its specialists and
superspecialists.

Yet we in medicine continue to exist in a system created in the Master
Builder era—a system in which a lone Master Physician with a prescription
pad, an operating room, and a few people to follow his lead plans and



executes the entirety of care for a patient, from diagnosis through treatment.
We’ve been slow to adapt to the reality that, for example, a third of patients
have at least ten specialist physicians actively involved in their care by their
last year of life, and probably a score more personnel, ranging from nurse
practitioners and physician assistants to pharmacists and home medical
aides. And the evidence of how slow we’ve been to adapt is the
extraordinarily high rate at which care for patients is duplicated or flawed
or completely uncoordinated.

In the construction business, Salvia explained, such failure is not an
option. No matter how complex the problems he faced in designing that
first shopping mall roof, he very quickly understood that he had no margin
for error. Perhaps it’s the large number of people who would die if his roof
collapsed under the weight of snow. Or perhaps it’s the huge amount of
money that would be lost in the inevitable lawsuits. But, whatever the
reason, architects, engineers, and builders were forced long ago—going
back to the early part of the last century—to confront the fact that the
Master Builder model no longer worked. So they abandoned it. They found
a different way to make sure they get things right.

To show me what they do, Salvia had me come to see one of the
construction sites where he and his team were working. His firm happened
to have a job under way a short, sunny walk from his office. The Russia
Wharf building was going to be a sprawling thirty-two-story, 700,000-
square-foot office and apartment complex. Its footprint alone was two acres.

The artistic renderings were spectacular. Russia Wharf was where
merchant ships sailing between St. Petersburg and Boston with iron, hemp,
and canvas for the shipbuilding industry once docked. The Boston Tea Party
took place next door. The new glass and steel building was going up right
along this waterfront, with a ten-story atrium underneath and the 110-year-
old brick facades of the original Classical Revival structures preserved as
part of the new building.

When I arrived for the tour, Salvia took one look at my blue Brooks
Brothers blazer and black penny loafers and let out a low chuckle.

“One thing you learn going to construction sites is you have to have the
right shoes,” he said.

The insides of the old buildings had long been gutted and the steel
skeleton of the new tower had been built almost halfway up, to the



fourteenth floor. A tower crane hung four stories above the structure. Ants
on the ground, we worked our way around a pair of concrete mixing trucks,
the cops stopping traffic, and a few puddles of gray mud to enter the first-
floor field office of John Moriarty and Associates, the general contractor for
the project. It was nothing like the movie construction-site field trailers I
had in my mind—no rusting coffee urn, no cheap staticky radio playing, no
cigar-chewing boss barking orders. Instead, there were half a dozen offices
where men and women, many in work boots, jeans, and yellow safety
reflector vests, sat staring into computer terminals or were gathered around
a conference table with a PowerPoint slide up on a screen.

I was given a blue hard hat and an insurance release to sign and
introduced to Finn O’Sullivan, a smiling six-foot-three Irishman with a
lilting brogue who served as the “project executive” for the building—they
don’t call them field bosses anymore, I was told. O’Sullivan said that on
any given day he has between two and five hundred workers on-site,
including people from any of sixty subcontractors. The volume of
knowledge and degree of complexity he had to manage, it struck me, were
as monstrous as anything I had encountered in medicine. He tried to explain
how he and his colleagues made sure that all those people were doing their
work correctly, that the building would come together properly, despite the
enormous number of considerations—and despite the fact that he could not
possibly understand the particulars of most of the tasks involved. But I
didn’t really get his explanation until he brought me to the main conference
room. There, on the walls around a big white oval table, hung sheets of
butcher-block-size printouts of what were, to my surprise, checklists.

Along the right wall as we walked in was, O’Sullivan explained, the
construction schedule. As I peered in close, I saw a line-byline, day-by-day
listing of every building task that needed to be accomplished, in what order,
and when—the fifteenth-floor concrete pour on the thirteenth of the month,
a steel delivery on the fourteenth, and so on. The schedule spread over
multiple sheets. There was special color coding, with red items highlighting
critical steps that had to be done before other steps could proceed. As each
task was accomplished, a job supervisor reported to O’Sullivan, who then
put a check mark in his computer scheduling program. He posted a new
printout showing the next phase of work each week, sometimes more



frequently if things were moving along. The construction schedule was
essentially one long checklist.

Since every building is a new creature with its own particularities, every
building checklist is new, too. It is drawn up by a group of people
representing each of the sixteen trades, including, in this case, someone
from Salvia’s firm making sure the structural engineering steps were
incorporated as they should be. Then the whole checklist is sent to the
subcontractors and other independent experts so they can double-check that
everything is correct, that nothing has been missed.

What results is remarkable: a succession of day-by-day checks that guide
how the building is constructed and ensure that the knowledge of hundreds,
perhaps thousands, is put to use in the right place at the right time in the
right way.

The construction schedule for the Russia Wharf project was designed to
build the complex up in layers, and I could actually see those layers when
Bernie Rouillard, Salvia’s lead structural engineer for the project, took me
on a tour. I should mention here that I am not too fond of heights. But I put
on my hard hat and followed Rouillard—past the signs that said
WARNING: CONSTRUCTION PERSONNELONLY, around a rusting nest
of discarded rebar, over a trail of wood planks that served as a walkway into
the building, and then into an orange cage elevator that rattled its way up
the side of the skeleton to the fourteenth floor. We stepped out onto a vast,
bare, gray slab floor with no walls, just twelve-foot vertical steel columns
ringing the outside, a massive rectangular concrete core in the center, and
the teeming city surrounding us.

“You can see everything from here,” Rouillard said, beckoning me to join
him out on the edge. I crept to within three feet and tried not to dwell on the
wind whipping through us or the vertiginous distance to the ground as he
good-naturedly pointed out the sites along the waterfront below. I did better
when we turned our backs to the city and he showed me the bare metal
trusses that had been put into the ceiling to support the floor being built
above.

Next, he said, will come the fireproofers.
“You have to fireproof metal?” I asked.
Oh yes, he said. In a fire, the metal can plasticize—lose its stiffness and

bend like spaghetti. This was why the World Trade Center buildings



collapsed, he said. He walked me down a stairway to the floor below us.
Here, I could see, the fire proofing material had been sprayed on, a gypsum-
based substance that made the ceiling trusses look gray and woolly.

We went down a couple more floors and he showed me that the “skin” of
the building had now been hung at those levels. The tall, shiny glass and
steel exterior had been bolted into the concrete floors every few feet. The
farther down we went, the more the layers had advanced. One team of
subcontractors had put up walls inside the skin. The pipefitters had then put
in water and drainage pipes. The tin knockers followed and installed the
ventilation ducts. By the time we got down to the lowest floors, the
masonry, electrical wiring, plumbing, and even some fixtures like staircase
railings were all in place. The whole intricate process was astounding to
behold.

On the upper floors, however, I couldn’t help but notice something that
didn’t look right, even to my untrained eyes. There had been rain recently
and on each of the open floors large amounts of water had pooled in the
same place—up against the walls of the inner concrete core. It was as if the
floor were tilted inward, like a bowl. I asked Rouillard about this.

“Yeah, the owners saw that and they weren’t too happy,” he said. He
explained what he thinks had happened. The immense weight of the
concrete core combined with the particular makeup of the soil underneath
had probably caused the core to settle sooner than anticipated. Meanwhile,
the outer steel frame had not yet been loaded with weight—there were still
eighteen stories to be built upon it—and that’s why he believes the floor had
begun to tip inward. Once the steel frame was loaded, he fully expected the
floor to level out.

The fascinating thing to me wasn’t his explanation. I had no idea what to
make of his answer. But here was a situation that hadn’t been anticipated on
the construction checklist: the tilting of the upper floors. At a minimum, a
water cleanup would be needed and the schedule adjusted for it. That alone
could throw the builders’ tidy plans off track. Furthermore, the people
involved had to somehow determine whether the tilting indicated a serious
construction defect. I was curious to know how they handled this question,
for there was inevitable uncertainty. How could they know that the problem
was just ordinary settling, that loading the steel frame would in fact level



out the floor? As Rouillard acknowledged, “variances can occur.” This was
a situation of true complexity.

Back down in the field office, I asked Finn O’Sullivan how he and his
team dealt with such a circumstance. After all, skyscraper builders must run
into thousands like it—difficulties they could never have predicted or
addressed in a checklist designed in advance. The medical way of dealing
with such problems—with the inevitable nuances of an individual patient
case—is to leave them to the expert’s individual judgment. You give the
specialist autonomy. In this instance, Rouillard was the specialist. Had the
building site been a hospital ward, his personal judgment would hold sway.

This approach has a flaw, however, O’Sullivan pointed out. Like a
patient, a building involves multiple specialists—the sixteen trades. In the
absence of a true Master Builder—a supreme, all-knowing expert with
command of all existing knowledge— autonomy is a disaster. It produces
only a cacophony of incompatible decisions and overlooked errors. You get
a building that doesn’t stand up straight. This sounded to me like medicine
at its worst.

So what do you do? I asked.
That was when O’Sullivan showed me a different piece of paper hanging

in his conference room. Pinned to the left-hand wall opposite the
construction schedule was another butcher-block-size sheet almost identical
in form, except this one, O’Sulli-van said, was called a “submittal
schedule.” It was also a checklist, but it didn’t specify construction tasks; it
specified communication tasks. For the way the project managers dealt with
the unexpected and the uncertain was by making sure the experts spoke to
one another—on X date regarding Y process. The experts could make their
individual judgments, but they had to do so as part of a team that took one
another’s concerns into account, discussed unplanned developments, and
agreed on the way forward. While no one could anticipate all the problems,
they could foresee where and when they might occur. The checklist
therefore detailed who had to talk to whom, by which date, and about what
aspect of construction—who had to share (or “submit”) particular kinds of
information before the next steps could proceed.

The submittal schedule specified, for instance, that by the end of the
month the contractors, installers, and elevator engineers had to review the
condition of the elevator cars traveling up to the tenth floor. The elevator



cars were factory constructed and tested. They were installed by experts.
But it was not assumed that they would work perfectly. Quite the opposite.
The assumption was that anything could go wrong, anything could get
missed. What? Who knows? That’s the nature of complexity. But it was
also assumed that, if you got the right people together and had them take a
moment to talk things over as a team rather than as individuals, serious
problems could be identified and averted.

So the submittal schedule made them talk. The contractors had to talk
with the installers and elevator engineers by the thirty-first. They had to talk
about fire protection with the fireproofers by the twenty-fifth. And two
weeks earlier, they had been required to talk about the condition of the core
wall and flooring on the upper floors, where the water had pooled, with the
structural engineers, a consultant, and the owners.

I saw that the box had been checked. The task was done. I asked
Rouillard how the discussion had gone.

Very well, he said. Everyone met and reviewed the possibilities. The
owners and the contractors were persuaded that it was reasonable to expect
the floor to level out. Cleanup was arranged, the schedule was adjusted, and
everyone signed off.

In the face of the unknown—the always nagging uncertainty about
whether, under complex circumstances, things will really be okay— the
builders trusted in the power of communication. They didn’t believe in the
wisdom of the single individual, of even an experienced engineer. They
believed in the wisdom of the group, the wisdom of making sure that
multiple pairs of eyes were on a problem and then letting the watchers
decide what to do.

Man is fallible, but maybe men are less so.
In a back room of the field office, Ryan Walsh, a buzz-cut young man of

about thirty wearing a yellow reflector vest, sat in front of two big flat-
screen displays. His job, he explained, was to take all the construction plans
submitted by each of the major trades and merge them into a three-
dimensional floor-by-floor computer rendering of the building. He showed
me what the top floor looked like on the screen. He’d so far loaded in the
specifications from nine of the trades—the structural specs, the elevator
specs, the plumbing specs, and so on. He used his mouse to walk us through



the building as if we were taking a stroll down the corridors. You could see
the walls, the doors, the safety valves, everything. More to the point, you
could see problems—a place where there wasn’t enough overhead clearance
for an average-size person, for example. He showed me an application
called Clash Detective that ferreted out every instance in which the different
specs conflicted with one another or with building regulations.

“If a structural beam is going where a lighting fixture is supposed to
hang, the Clash Detective turns that beam a different color on-screen,” he
said. “You can turn up hundreds of clashes. I once found two thousand.”
But it’s not enough to show the clash on the screen, he explained. You have
to resolve it, and to do that you have to make sure the critical people talk.
So the computer also flags the issue for the submittal schedule printout and
sends an e-mail to each of the parties who have to resolve it.

There’s yet another program, called Project Center, 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. When
we were back at the McNamara/Salvia offices, Bernie Rouillard showed me
one such e-mail he’d gotten that week. 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.

Joe Salvia had earlier told me that the major advance in the science of
construction over the last few decades has been the perfection of tracking
and communication. But only now did I understand what he meant.

The building world’s willingness to apply its strategies to difficulties of
any size and seriousness is striking. Salvia’s partner, Robert McNamara, for
instance, was one of the structural engineers for the Citicorp (now
Citigroup) building in midtown Manhattan, with its iconic slanted rooftop.



It was planned to rise more than nine hundred feet on four nine-story-tall
stiltlike columns placed not at the building’s corners but at the center of
each side and steadied by giant, hidden chevron-shaped braces designed by
William LeMessurier, the project’s lead structural engineer. The visual
effect was arresting. The colossal structure would look like it was almost
floating above Fifty-third Street. But wind-tunnel testing of a model
revealed that the skyscraper stood so high above the surrounding buildings
in midtown that it was subject to wind streams and turbulence with forces
familiar only to airplane designers, not to structural engineers. The
acceptable amount of sway for the building was unknown.

So what did they do? They did not scrap the building or shrink it to a less
ambitious size. Instead, McNamara proposed a novel solution called a
“tuned mass damper.” They could, he suggested, suspend an immense four-
hundred-ton concrete block from huge springs in the building’s crown on
the fifty-ninth floor, so that when wind pitched the building one way, the
block would swing the other way and steady it.

The solution was brilliant and elegant. The engineers did some wind-
tunnel testing with a small model of the design, and the results were highly
reassuring. Nonetheless, some chance of error and unpredictability always
remains in projects of this complexity. So the builders reduced their margin
of error the best way they knew how—by taking a final moment to make
sure that everyone talked it through as a group. The building owner met
with the architect, someone from the city buildings department, the
structural engineers, and others. They reviewed the idea and all the
calculations behind it. They confirmed that every concern they could think
of had been addressed. Then they signed off on the plan, and the skyscraper
was built.

It is unnerving to think that we allow buildings this difficult to design and
construct to go up in the midst of our major cities, with thousands of people
inside and tens of thousands more living and working nearby. Doing so
seems risky and unwise. But we allow it based on trust in the ability of the
experts to manage the complexities. They in turn know better than to rely
on their individual abilities to get everything right. They trust instead in one
set of checklists to make sure that simple steps are not missed or skipped
and in another set to make sure that everyone talks through and resolves all
the hard and unexpected problems.



“The biggest cause of serious error in this business is a failure of
communication,” O’Sullivan told me.

In the Citicorp building, for example, the calculations behind the designs
for stabilizing the building assumed the joints in those giant braces at the
base of the building would be welded. Joint welding, however, is labor
intensive and therefore expensive. Bethlehem Steel, which took the contract
to erect the tower, proposed switching to bolted joints, which are not as
strong. They calculated that the bolts would do the job. But, as a New
Yorker story later uncovered, their calculations were somehow not reviewed
with LeMessurier. That checkpoint was bypassed.

It is not certain that a review would have led him to recognize a problem
at the time. But in 1978, a year after the building opened, LeMessurier,
prompted by a question from a Princeton engineering student, discovered
the change. And he found it had produced a fatal flaw: the building would
not be able to withstand seventy-mile-an-hour winds—which, according to
weather tables, would occur at least once every fifty-five years in New York
City. In that circumstance, the joints would fail and the building would
collapse, starting on the thirtieth floor. By now, the tower was fully
occupied. LeMessurier broke the news to the owners and to city officials.
And that summer, as Hurricane Ella made its way toward the city, an
emergency crew worked at night under veil of secrecy to weld two-inch-
thick steel plates around the two hundred critical bolts, and the building was
secured. The Citicorp tower has stood solidly ever since.

The construction industry’s checklist process has clearly not been
foolproof at catching problems. Nonetheless, its record of success has been
astonishing. In the United States, we have nearly five million commercial
buildings, almost one hundred million low-rise homes, and eight million or
so high-rise residences. We add somewhere around seventy thousand new
commercial buildings and one million new homes each year. But “building
failure”—defined as a partial or full collapse of a functioning structure—is
exceedingly rare, especially for skyscrapers. According to a 2003 Ohio
State University study, the United States experiences an average of just
twenty serious “building failures” per year. That’s an annual avoidable
failure rate of less than 0.00002 percent. And, as Joe Salvia explained tome,
although buildings are now more complex and sophisticated than ever in
history, with higher standards expected for everything from earthquake



proofing to energy efficiency, they take a third less time to build than they
did when he started his career.

The checklists work.



4. THE IDEA

There is a particularly tantalizing aspect to the building industry’s
strategy for getting things right in complex situations: it’s that it gives
people power. In response to risk, most authorities tend to centralize power
and decision making. That’s usually what checklists are about—dictating
instructions to the workers below to ensure they do things the way we want.
Indeed, the first building checklist I saw, the construction schedule on the
right-hand wall of O’Sullivan’s conference room, was exactly that. It
spelled out to the tiniest detail every critical step the tradesmen were
expected to follow and when—which is logical if you’re confronted with
simple and routine problems; you want the forcing function.

But the list on O’Sullivan’s other wall revealed an entirely different
philosophy about power and what should happen to it when you’re
confronted with complex, nonroutine problems— such as what to do when
a difficult, potentially dangerous, and unanticipated anomaly suddenly
appears on the fourteenth floor of a thirty-two-story skyscraper under
construction. The philosophy is that you push the power of decision making
out to the periphery and away from the center. You give people the room to
adapt, based on their experience and expertise. All you ask is that they talk
to one another and take responsibility. That is what works.

The strategy is unexpectedly democratic, and it has become standard
nowadays, O’Sullivan told me, even in building inspections. The inspectors
do not recompute the wind-force calculations or decide whether the joints in
a given building should be bolted or welded, he said. Determining whether
a structure like Russia Wharf or my hospital’s new wing is built to code and
fit for occupancy involves more knowledge and complexity than any one
inspector could possibly have. So although inspectors do what they can to
oversee a building’s construction, mostly they make certain the builders
have the proper checks in place and then have them sign affidavits attesting



that they themselves have ensured that the structure is up to code.
Inspectors disperse the power and the responsibility.

“It makes sense,” O’Sullivan said. “The inspectors have more troubles
with the safety of a two-room addition from a do-it-yourselfer than they do
with projects like ours. So that’s where they focus their efforts.” Also, I
suspect, at least some authorities have recognized that when they don’t let
go of authority they fail. We need look no further than what happened after
Hurricane Katrina hit New Orleans.

At 6:00 a.m., on August 29, 2005, Katrina made landfall in Plaquemines
Parish in New Orleans. The initial reports were falsely reassuring. With
telephone lines, cell towers, and electrical power down, the usual sources of
information were unavailable. By afternoon, the levees protecting the city
had been breached. Much of New Orleans was under water. The evidence
was on television, but Michael Brown, the director of the Federal
Emergency Management Agency, discounted it and told a press conference
that the situation was largely under control.

FEMA was relying on information from multiple sources, but only one
lone agent was actually present in New Orleans. That agent had managed to
get a Coast Guard helicopter ride over the city that first afternoon, and he
filed an urgent report the only way he could with most communication lines
cut—by e-mail. Flooding was widespread, the e-mail said; he himself had
seen bodies floating in the water and hundreds of people stranded on
rooftops. Help was needed. But the government’s top officials did not use e-
mail. And as a Senate hearing uncovered, they were not apprised of the
contents of the message until the next day.

By then, 80 percent of the city was flooded. Twenty thousand refugees
were stranded at the New Orleans Superdome. Another twenty thousand
were at the Ernest N. Morial Convention Center. Over five thousand people
were at an overpass on Interstate 10, some of them left by rescue crews and
most carrying little more than the clothes on their backs. Hospitals were
without power and suffering horrendous conditions. As people became
desperate for food and water, looting began. Civil breakdown became a
serious concern.

Numerous local officials and impromptu organizers made efforts to
contact authorities and let them know what was needed, but they too were
unable to reach anyone. When they finally got a live person on the phone,



they were told to wait—their requests would have to be sent up the line.
The traditional command-and-control system rapidly became over
whelmed. There were too many decisions to be made and too little
information about precisely where and what help was needed.

Nevertheless, the authorities refused to abandon the traditional model.
For days, while conditions deteriorated hourly, arguments roared over who
had the power to provide the resources and make decisions. The federal
government wouldn’t yield the power to the state government. The state
government wouldn’t give it to the local government. And no one would
give it to people in the private sector.

The result was a combination of anarchy and Orwellian bureaucracy with
horrifying consequences. Trucks with water and food were halted or
diverted or refused entry by authorities— the supplies were not part of their
plan. Bus requisitions were held up for days; the official request did not
even reach the U.S. Department of Transportation until two days after tens
of thousands had become trapped and in need of evacuation. Meanwhile
two hundred local transit buses were sitting idle on higher ground nearby.

The trouble wasn’t a lack of sympathy among top officials. It was a lack
of understanding that, in the face of an extraordinarily complex problem,
power needed to be pushed out of the center as far as possible. Everyone
was waiting for the cavalry, but a centrally run, government-controlled
solution was not going to be possible.

Asked afterward to explain the disastrous failures, Michael Chertoff,
secretary of Homeland Security, said that it had been an “ultra-catastrophe,”
a “perfect storm” that “exceeded the foresight of the planners, and maybe
anybody’s foresight.” But that’s not an explanation. It’s simply the
definition of a complex situation. And such a situation requires a different
kind of solution from the command-and-control paradigm officials relied
on.

Of all organizations, it was oddly enough Wal-Mart that best recognized
the complex nature of the circumstances, according to a case study from
Harvard’s Kennedy School of Government. Briefed on what was
developing, the giant discount retailer’s chief executive officer, Lee Scott,
issued a simple edict. “This company will respond to the level of this
disaster,” he was remembered to have said in a meeting with his upper



management. “A lot of you are going to have to make decisions above your
level. Make the best decision that you can with the information that’s
available to you at the time, and, above all, do the right thing.”

As one of the officers at the meeting later recalled, “That was it.” The
edict was passed down to store managers and set the tone for how people
were expected to react. On the most immediate level, Wal-Mart had 126
stores closed due to damage and power outages. Twenty thousand
employees and their family members were displaced. The initial focus was
on helping them. And within forty-eight hours, more than half of the
damaged stores were up and running again. But according to one executive
on the scene, as word of the disaster’s impact on the city’s population began
filtering in from Wal-Mart employees on the ground, the priority shifted
from reopening stores to “Oh, my God, what can we do to help these
people?”

Acting on their own authority, Wal-Mart’s store managers began
distributing diapers, water, baby formula, and ice to residents. Where
FEMA still hadn’t figured out how to requisition supplies, the managers
fashioned crude paper-slip credit systems for first responders, providing
them with food, sleeping bags, toiletries, and also, where available, rescue
equipment like hatchets, ropes, and boots. The assistant manager of a Wal-
Mart store engulfed by a thirty-foot storm surge ran a bulldozer through the
store, loaded it with any items she could salvage, and gave them all away in
the parking lot. When a local hospital told her it was running short of drugs,
she went back in and broke into the store’s pharmacy—and was lauded by
upper management for it.

Senior Wal-Mart officials concentrated on setting goals, measuring
progress, andmaintaining communication lines with employees at the front
lines and with official agencies when they could. In other words, to handle
this complex situation, they did not issue instructions. Conditions were too
unpredictable and constantly changing. They worked on making sure
people talked. Wal-Mart’s emergency operations team even included a
member of the Red Cross. (The federal government declined Wal-Mart’s
invitation to participate.) The team also opened a twenty-four-hour call
center for employees, which started with eight operators but rapidly
expanded to eighty to cope with the load.



Along the way, the team discovered that, given common goals to do what
they could to help and to coordinate with one another, Wal-Mart’s
employees were able to fashion some extraordinary solutions. They set up
three temporary mobile pharmacies in the city and adopted a plan to
provide medications for free at all of their stores for evacuees with
emergency needs—even without a prescription. They set up free check
cashing for payroll and other checks in disaster-area stores. They opened
temporary clinics to provide emergency personnel with inoculations against
flood-borne illnesses. And most prominently, within just two days of
Katrina’s landfall, the company’s logistics teams managed to contrive ways
to get tractor trailers with food, water, and emergency equipment past
roadblocks and into the dying city. They were able to supply water and food
to refugees and even to the National Guard a day before the government
appeared on the scene. By the end Wal-Mart had sent in a total of 2,498
trailer loads of emergency supplies and donated $3.5 million in
merchandise to area shelters and command centers.

“If the American government had responded like Wal-Mart has
responded, we wouldn’t be in this crisis,” Jefferson Parish’s top official,
Aaron Broussard, said in a network television interview at the time.

The lesson of this tale has been misunderstood. Some have argued that the
episode proves that the private sector is better than the public sector in
handling complex situations. But it isn’t. For every Wal-Mart, you can find
numerous examples of major New Orleans businesses that proved
inadequately equipped to respond to the unfolding events—from the utility
corporations, which struggled to get the telephone and electrical lines
working, to the oil companies, which kept too little crude oil and refinery
capacity on hand for major disruptions. Public officials could also claim
some genuine successes. In the early days of the crisis, for example, the
local police and firefighters, lacking adequate equipment, recruited an
armada of Louisiana sportsmen with flat-bottom boats and orchestrated a
breathtaking rescue of more than sixty-two thousand people from the water,
rooftops, and attics of the deluged city.

No, the real lesson is that under conditions of true complexity—where the
knowledge required exceeds that of any individual and unpredictability
reigns—efforts to dictate every step from the center will fail. People need



room to act and adapt. Yet they cannot succeed as isolated individuals,
either—that is anarchy. Instead, they require a seemingly contradictory mix
of freedom and expectation—expectation to coordinate, for example, and
also to measure progress toward common goals.

This was the understanding people in the skyscraper-building industry
had grasped. More remarkably, they had learned to codify that
understanding into simple checklists. They had made the reliable
management of complexity a routine.

That routine requires balancing a number of virtues: freedom and
discipline, craft and protocol, specialized ability and group collaboration.
And for checklists to help achieve that balance, they have to take two
almost opposing forms. They supply a set of checks to ensure the stupid but
critical stuff is not overlooked, and they supply another set of checks to
ensure people talk and coordinate and accept responsibility while
nonetheless being left the power to manage the nuances and
unpredictabilities the best they know how.

I came away from Katrina and the builders with a kind of theory: under
conditions of complexity, not only are checklists a help, they are required
for success. There must always be room for judgment, but judgment aided
— and even enhanced— by procedure.

Having hit on this “theory,” I began to recognize checklists in odd
corners everywhere—in the hands of professional football coordinators,
say, or on stage sets. Listening to the radio, I heard the story behind rocker
David Lee Roth’s notorious insistence that Van Halen’s contracts with
concert promoters contain a clause specifying that a bowl of M&M’s has to
be provided backstage, but with every single brown candy removed, upon
pain of forfeiture of the show, with full compensation to the band. And at
least once, Van Halen followed through, peremptorily canceling a show in
Colorado when Roth found some brown M&M’s in his dressing room. This
turned out to be, however, not another example of the insane demands of
power-mad celebrities but an ingenious ruse.

As Roth explained in his memoir, Crazy from the Heat, “Van Halen was
the first band to take huge productions into tertiary, third-level markets.
We’d pull up with nine eighteen-wheeler trucks, full of gear, where the
standard was three trucks, max. And there were many, many technical
errors—whether it was the girders couldn’t support the weight, or the



flooring would sink in, or the doors weren’t big enough to move the gear
through. The contract rider read like a version of the Chinese Yellow Pages
because there was so much equipment, and so many human beings to make
it function.” So just as a little test, buried somewhere in the middle of the
rider, would be article 126, the no-brown-M&M’s clause. “When I would
walk backstage, if I saw a brown M&M in that bowl,” he wrote, “well,
we’d line-check the entire production. Guaranteed you’re going to arrive at
a technical error. . . . Guaranteed you’d run into a problem.” These weren’t
trifles, the radio story pointed out. The mistakes could be life-threatening.
In Colorado, the band found the local promoters had failed to read the
weight requirements and the staging would have fallen through the arena
floor.

“David Lee Roth had a checklist!” I yelled at the radio.
I ran my theory—about the necessity of checklists—by Jody Adams, the

chef and owner of Rialto, one of my favorite restaurants in Boston. In the
early 1990s, Food and Winemagazine named her one of America’s ten best
new chefs, and in 1997 she won a James Beard Foundation Best Chef
award, which is the Oscar for food. Rialto is frequently mentioned on
national best-restaurant lists, most recently Esquire magazine’s. Her focus
is on regional Italian cuisine, though with a distinctive take.

Adams is self-taught. An anthropology major at Brown University, she
never went to culinary school. “But I had a thing for food,” as she puts it,
and she went to work in restaurants, learning her way from chopping onions
to creating her own style of cooking.

The level of skill and craft she has achieved in her restaurant is daunting.
Moreover, she has sustained it for many years now. I was interested in how
she did it. I understood perfectly well how the Burger Kings and Taco Bells
of the world operate. They are driven by tightly prescribed protocol. They
provide Taylorized, assembly-line food. But in great restaurants the food is
ever-evolving, refined, and individual. Nevertheless, they have to produce
an extraordinary level of excellence day after day, year after year, for one to
three hundred people per night. I had my theory of how such perfectionism
is accomplished, but was it true? Adams invited me in to see.

I spent one Friday evening perched on a stool in Rialto’s long and narrow
kitchen amid the bustle, the shouting, the grill flaming on one side, the deep
fryer sizzling on another. Adams and her staff served 150 people in five



hours. That night, they made a roasted tomato soap with sweated onions
and garlic; squid ink ravioli filled with a salt cod brandade on a bed of
squash blossoms and lobster sauce; grilled bluefish with corn relish,
heirloom tomatoes, and pickled peppers; slow-roasted duck marinated in
soy sauce, balsamic vinegar, mustard, rosemary, and garlic; and three dozen
other mouthwatering dishes.

Sitting there, I saw remarkable expertise. Half of Adams’s staff had been
to culinary school. Few had less than a decade of experience. They each had
a kitchen specialty. There was a pastry chef, baker, grill chef, fry cook,
dessert chef, sous chef, sommelier— you get the picture. Through the years,
they had perfected their technique. I couldn’t fathom the subtleties of most
of what they did. Though I am a surgeon, they wouldn’t let me anywhere
near their knives. Jay, the pasta chef, showed me how to heat butter
properly and tell by sight when gnocchi were perfectly boiled. Adams
showed me how much a pinch of salt really was.

People celebrate the technique and creativity of cooking. Chefs are
personalities today, and their daring culinary exploits are what make the
television cooking shows so popular. But as I saw at Rialto, it’s discipline—
uncelebrated and untelevised—that keeps the kitchen clicking. And sure
enough, checklists were at the center of that discipline.

First there was the recipe—the most basic checklist of all. Every dish had
one. The recipes were typed out, put in clear plastic sleeves, and placed at
each station. Adams was religious about her staff ’s using them. Even for
her, she said, “following the recipe is essential to making food of consistent
quality over time.”

Tacked to a bulletin board beside the dessert station was what Adams
called her Kitchen Notes—e-mails to the staff of her brief observations
about the food. The most recent was from 12:50 the previous night.
“Fritters—more herbs, more garlic . . . more punch,” it said. “Corn silk in
corn! Creamed corn side on oval plates—not square! Mushrooms—more
shallots, garlic, and marsala. USE THE RECIPES!”

The staff didn’t always love following the recipes. You make the creamed
corn a few hundred times and you believe you have it down. But that’s
when things begin to slip, Adams said.

The recipes themselves were not necessarily static. All the ones I saw had
scribbled modifications in the margins—many of them improvements



provided by staff. Sometimes there would be a wholesale revamp.
One new dish they were serving was a split whole lobster in a cognac and

fish broth reduction with littleneck clams and chorizo. The dish is Adams’s
take on a famous Julia Child recipe. Before putting a dish on the menu,
however, she always has the kitchen staff make a few test runs, and some
problems emerged. Her recipe called for splitting a lobster and then
sautéing it in olive oil. But the results proved too variable. Too often the
lobster meat was either overcooked or undercooked. The sauce was also
made to order, but it took too long for the eight-to-ten-minute turnaround
that customers expect.

So she and two of her chefs reengineered the dish. They decided to make
the sauce in advance and parboil the lobster ahead of time, as well. On
repeated test runs, the lobster came out perfectly. The recipe was rewritten.

There was also a checklist for every customer. When an order was placed
up front, it was printed out on a slip back in the kitchen. The ticket specified
the dishes ordered, the table number, the seat number, any preferences
required by the customer or noted in a database from previous visits—food
allergies, for instance, or how the steak should be cooked, or whether this
was a special occasion like a birthday or a visit from a VIP whom Adams
needed to go out and say hello to. The sous chef, who serves as a kind of
field officer for operations, read the tickets off as they came in.

“Fire mushrooms. Fire mozz. Lobo on hold. Steak very well done, no
gluten, on hold.”

“Fire” meant cook it now. “On hold” meant it was a second course.
“Lobo” was the lobster. The steak needed to be cooked all the way through
and the customer had a gluten allergy. A read-back was expected to confirm
that the line cooks had heard the order right.

“Fire mushrooms. Fire mozz,” said one.
“Lobo on hold,” said the seafood cook.
“Steak very well done, no gluten, on hold,” said the grill chef. As in the

construction world, however, not everything could be anticipated and
reduced to a recipe. And so Adams, too, had developed a communication
checklist to ensure people recognized, and dealt with, unexpected problems
as a team. At five o’clock, half an hour before opening, the staff holds what
she calls the “pow wow.” Everyone gathers in the kitchen for a quick check
to discuss unanticipated issues and concerns—the unpredictable. The night



I was there, they reviewed the reservation count, two menu changes, how to
fill in for a sick staff member, and a sweet sixteen party with twenty girls
who were delayed and going to arrive in the midst of the dinner rush.
Everyone was given a chance to speak, and they made plans for what to do.

Of course, this still couldn’t guarantee everything would go right. There
remained plenty of sources of uncertainty and imperfection: a soup might
be plated too early and allowed to cool, a quail might have too little sauce, a
striped bass might come off the grill too dry. So Adams had one final check
in place. Every plate had to be reviewed by either her or the sous chef
before it left the kitchen for the dining room. They made sure the food
looked the way it should, checked it against the order ticket, gave it a sniff
or, with a clean spoon, maybe even a taste.

I counted the dishes as they went by. At least 5 percent were sent back.
“This calamari has to be fried more,” the sous chef told the fry cook. “We
want more of a golden brown.”

Later, I got to try some of the results. I had the fried olives, the grilled
clams, the summer succotash, and a local farm green salad. I also had the
lobster. The food was incredible. I left at midnight with my stomach full
and my brain racing. Even here, in one of our most particularized and craft-
driven enterprises—in a way, Adams’s cooking is more art than science—
checklists were required. Everywhere I looked, the evidence seemed to
point to the same conclusion. There seemed no field or profession where
checklists might not help. And that might even include my own.



5. THE FIRST TRY

In late 2006, a woman with a British accent and a Geneva telephone
number called me. She said that she was from the World Health
Organization and she wanted to see whether I might help them organize a
group of people to solve a small problem. Officials were picking up
indications that the volume of surgery was increasing worldwide and that a
significant portion of the care was so unsafe as to be a public danger. So
they wanted to develop a global program to reduce avoidable deaths and
harm from surgery.

I believe my response was, “Um, how do you do that?”
“We’ll have a meeting,” she said.
I asked how much money they’d be devoting to the problem.
“Oh, there’s no real money,” she said.
I said no. I couldn’t do it. I was busy.
But she knew what she was about. She said something along the lines of,

“Oh, sorry. I thought you were supposed to be some kind of expert on
patient safety in surgery. My mistake.”

I agreed to help organize the meeting.

One of the benefits of joining up to work with WHO was gaining access to
the health system reports and data from the organization’s 193 member
countries. And compiling the available numbers in surgery, my research
team and I found that the WHO officials’ impression was correct: the global
volume of surgery had exploded. By 2004, surgeons were performing some
230 million major operations annually—one for every twenty-five human
beings on the planet—and the numbers have likely continued to increase
since then. The volume of surgery had grown so swiftly that, without
anyone’s quite realizing, it has come to exceed global totals for childbirth—
only with a death rate ten to one hundred times higher. Although most of
the time a given procedure goes just fine, often it doesn’t: estimates of
complication rates for hospital surgery range from 3 to 17 percent. While



incisions have gotten smaller and recoveries have gotten quicker, the risks
remain serious. Worldwide, at least seven million people a year are left
disabled and at least onemillion dead—a level of harm that approaches that
of malaria, tuberculosis, and other traditional public health concerns.

Peering at the numbers, I understood why WHO—an organization
devoted to solving large-scale public health problems— should suddenly
have taken an interest in something as seemingly specific and high-tech as
surgical care. Improvement in global economic conditions in recent decades
had produced greater longevity and therefore a greater need for essential
surgical services—for people with cancers, broken bones and other
traumatic injuries, complications during child delivery, major birth defects,
disabling kidney stones and gallstones and hernias. Although there
remained some two billion people, especially in rural areas, without access
to a surgeon, health systems in all countries were now massively increasing
the number of surgical procedures performed. As a result, the safety and
quality of that care had become a major issue everywhere.

But what could be done about it? Remedying surgery as a public health
matter is not like remedying, say, polio. I’d traveled with WHO physicians
overseeing the campaign to eradicate polio globally and seen how hard just
providing vaccines to a population could be. Surgery was drastically more
complex. Finding ways to reduce its harm in a single hospital seemed
difficult enough. Finding a way that could reach every operating room in
the world seemed absurd. With more than twenty-five hundred different
surgical procedures, ranging from brain biopsies to toe amputations,
pacemaker insertions to spleen extractions, appendectomies to kidney
transplants, you don’t even know where to start. Perhaps, I thought, I could
work with WHO to focus on reducing the harmof just one procedure—
much like with central lines—but how much of a dent would that make in a
problem of this scale?

In January 2007, at WHO headquarters in Geneva, we convened a two-
day meeting of surgeons, anesthesiologists, nurses, safety experts, even
patients from around the world to puzzle through what could be done. We
had clinicians from top facilities in Europe, Canada, and the United States.
We had the chief surgeon for the International Committee of the Red Cross,
who had sent teams to treat sick and wounded refugees everywhere from
Mogadishu to Indonesia. We had a father from Zambia whose daughter



inadvertently suffocated from lack of oxygen during treatment. As the
group told stories of their findings and experiences with surgery around the
world, I became only more skeptical. How could we possibly attempt to
address so many different issues in so many different places?

A medical officer in his forties from western Ghana, where cocoa
growing and gold mining had brought a measure of prosperity, told of the
conditions in his district hospital. No surgeon was willing to stay, he said.
Ghanawas suffering from a brain drain, losing many of its highest skilled
citizens to better opportunities abroad. He told us his entire hospital had just
three medical officers—general physicians with no surgical training.
Nevertheless, when a patient arrives critically ill and bleeding after two
days in labor, or sick and feverish from appendicitis, or with a collapsed
lung after a motorbike crash, the untutored doctors do what they have to do.
They operate.

“You must understand,” he said. “I manage everything. I am the
pediatrician, obstetrician, surgeon, everything.” He had textbooks and a
manual of basic surgical techniques. He had an untrained assistant who had
learned how to give basic anesthesia. His hospital’s equipment was
rudimentary. The standards were poor. Things sometimes went wrong. But
he was convinced doing something was better than doing nothing at all.

A Russian bioengineer spoke. He’d spent much of his career overseeing
the supply and service of medical equipment to hospitals in different parts
of the world, and he described dangerous problems in both high- and low-
income settings: inadequately maintained surgical devices that have set fire
to patients or electrocuted them; new technologies used incorrectly because
teams had not received proper training; critical, lifesaving equipment that
was locked away in a cabinet or missing when people needed it.

The chief of surgery for the largest hospital in Mongolia described
shortages of pain control medications, and others from Asia, Africa, and the
Middle East recounted the same. A New Zealand researcher spoke of
terrifying death rates in poor countries from unsafe anesthesia, noting that
although some places in Africa had fewer than one in five thousand patients
die from general anesthesia, others had rates more than ten times worse,
with one study in Togo showing one in 150 died. An anesthesiologist from
India chimed in, tracing problems with anesthesia to the low respect most
surgeons accord anesthetists. In her country, she said, they shout



anesthetists down and disregard the safety issues that her colleagues raise.
Medical students see this and decide not to go into anesthesiology. As a
result, the most risky part of surgery—anesthesia—is done by untrained
people far more often than the surgery itself. A nurse from Ireland joined
the clamor. Nurses work under even worse conditions, she said. They are
often ignored as members of the team, condescended to, or fired for raising
concerns. She’d seen it in her home country, and from her colleagues
abroad she knew it to be the experience of nurses internationally.

On the one hand, everyone firmly agreed: surgery is enormously valuable
to people’s lives everywhere and should be made more broadly available.
Even under the grimmest conditions, it is frequently lifesaving. And in
much of the world, the serious complication rates seem acceptably low—in
the 5 to 15 percent range for hospital operations.

On the other hand, the idea that such rates are “acceptable” was hard to
swallow. Each percentage point, after all, represented millions left disabled
or dead. Studies in the United States alone had found that at least half of
surgical complications were preventable. But the causes and contributors
were of every possible variety. We needed to do something. What, though,
wasn’t clear.

Some suggested more training programs. The idea withered almost upon
utterance. If these failures were problems in every country—indeed, very
likely, in every hospital—no training program could be deployed widely
enough to make a difference. There was neither the money nor the capacity.

We discussed incentive approaches, such as the pay-for-performance
schemes recently initiated on a trial basis in the United States. In these
programs, clinicians receive financial rewards for being more consistent
about giving, say, heart attack patients the proper care or incur penalties for
not doing so. The strategy has shown results, but the gains have been
modest—the country’s largest pay-for-performance trial, for example,
registered just 2 to 4 percent improvement. Furthermore, the measurements
required for incentive payments are not easy to obtain. They rely on
clinicians’ self-reported results, which are not always accurate. The results
are also strongly affected by howsick patients are to begin with. One might
be tempted, for example, to pay surgeons with higher complication rates
less, but some might simply have sicker patients. The incentive programs



have thus far been expensive, incremental, and of limited benefit. Taking
them global was unimaginable.

The most straightforward thing for the group to do would have been to
formulate and publish under the WHO name a set of official standards for
safe surgical care. It is the approach expert panels commonly take. Such
guidelines could cover everything from measures to prevent infection in
surgery to expectations for training and cooperation in operating rooms.
This would be our Geneva Convention on Safe Surgery, our Helsinki
Accord to Stop Operating Room Mayhem.

But one had only to take a walk through the dim concrete basement
hallways of the otherwise soaring WHO headquarters to start doubting that
plan. Down in the basement, while taking a shortcut between buildings, I
saw pallet after pallet of two-hundred-page guideline books from other
groups that had been summoned to make their expert pronouncements.
There were guidelines stacked waist-high on malaria prevention, HIV/AIDS
treatment, and influenza management, all shrink-wrapped against the
gathering dust. The standards had been carefully written and were, I am
sure, wise and well considered. Some undoubtedly raised the bar of
possibility for achievable global standards. But in most cases, they had at
best trickled out into the world. At the bedsides of patients in Bangkok and
Brazzaville, Boston and Brisbane, little had changed.

I asked a WHO official whether the organization had a guidebook on how
to carry out successful global public health programs. She regarded me with
a look that a parent might give a toddler searching the dog’s mouth for the
thing that makes the barking noise. It’s a cute idea but idiotic.

I searched anyway. I asked people around WHO for examples of public
health interventions we could learn from. They came up with instances like
the smallpox vaccination campaign that eradicated the scourge from the
world in 1979 and the work of Dr. John Snow famously tracing a deadly
1854 London cholera outbreak to water in a public well. When the disease
struck a London neighborhood that summer, two hundred people died in the
first three days. Three-quarters of the area’s residents fled in panic.
Nonetheless, by the next week, some five hundred more died. The dominant
belief was that diseases like cholera were caused by “miasmas”—putrefied
air. But Snow, skeptical of the bad-air theory, made a map of where the
deceased had lived and found them clustered around a single water source,



a well in Soho’s Broad Street. He interviewed the bereaved families about
their habits. He made a careful statistical analysis of possible factors. And
he concluded that contaminated water had caused the outbreak. (It was later
discovered that the well had been dug next to a leaking cesspit.) Snow
persuaded the local council to remove the water well’s pump handle. This
disabled the well, ended the spread of the disease, and also established the
essential methods of outbreak investigation that infectious disease
specialists follow to this day.

All the examples, I noticed, had a few attributes in common: They
involved simple interventions—a vaccine, the removal of a pump handle.
The effects were carefully measured. And the interventions proved to have
widely transmissible benefits—what business types would term a large ROI
(return on investment) or what Archimedes would have called, merely,
leverage.

Thinking of these essential requirements—simple, measurable,
transmissible—I recalled one of my favorite public health studies. It was a
joint public health program conducted by the U.S. Centers for Disease
Control and HOPE, a charitable organization in Pakistan, to address the
perilous rates of premature death among children in the slums of Karachi.
The squatter settlements surrounding the megacity contained more than four
million people living under some of the most crowded and squalid
conditions in the world. Sewage ran in the streets. Chronic poverty and food
shortages left 30 to 40 percent of the children malnourished. Virtually all
drinking water sources were contaminated. One child in ten died before age
five—usually from diarrhea or acute respiratory infections.

The roots of these problems were deep and multifactorial. Besides
inadequate water and sewage systems, illiteracy played a part, hampering
the spread of basic health knowledge. Corruption, political instability, and
bureaucracy discouraged investment in local industry that might provide
jobs and money for families to improve their conditions. Low global
agriculture prices made rural farming life impossible, causing hundreds of
thousands to flock to the cities in search of work, which only increased the
crowding. Under these circumstances, it seemed unlikely that any
meaningful improvement in the health of children could be made without a
top-to-bottom reinvention of government and society.



But a young public health worker had an idea. Stephen Luby had grown
up in Omaha, Nebraska, where his father chaired the obstetrics and
gynecology faculty at Creighton University. He attended medical school at
the University of Texas Southwestern. But for some reason he was always
drawn to public health work. He took a CDC job investigating infectious
outbreaks in South Carolina, but when a position came open in the CDC’s
Pakistan office he jumped to take it. He arrived in Karachi with his
schoolteacher wife and began publishing his first investigations of
conditions there in the late nineties.

I had spoken to him once about how he thought through the difficulties.
“If we had the kinds of water and sewage systems we’ve got in Omaha, we
could solve these problems,” he said. “But you have to wait decades for
major infrastructure projects.” So instead, he said, he looked for low-tech
solutions. In this case, the solution he came up with was so humble it
seemed laughable to his colleagues. It was soap.

Luby learned that Procter & Gamble, the consumer product
conglomerate, was eager to prove the value of its new antibacterial
Safeguard soap. So despite his colleagues’ skepticism, he persuaded the
company to provide a grant for a proper study and to supply cases of
Safeguard both with and without triclocarban, an antibacterial agent. Once a
week, field-workers from HOPE fanned out through twenty-five randomly
chosen neighborhoods in the Karachi slums distributing the soap, some with
the antibacterial agent and some without. They encouraged people to use it
in six situations: to wash their bodies once daily and to wash their hands
every time they defecated, wiped an infant, or were about to eat, prepare
food, or feed it to others. The field-workers then collected information on
illness rates among children in the test neighborhoods, as well as in eleven
control neighborhoods, where no soap was distributed.

Luby and his team reported their results in a landmark paper published in
the Lancet in 2005. Families in the test neighborhoods received an average
of 3.3 bars of soap per week for one year. During this period, the incidence
of diarrhea among children in these neighborhoods fell 52 percent
compared to that in the control group, no matter which soap was used. The
incidence of pneumonia fell 48 percent. And the incidence of impetigo, a
bacterial skin infection, fell 35 percent. These were stunning results. And
they were achieved despite the illiteracy, the poverty, the crowding, and



even the fact that, however much soap they used, people were still drinking
and washing with contaminated water.

Ironically, Luby said, Procter & Gamble considered the study something
of a disappointment. His research team had found no added benefit from
having the antibacterial agent in the soap. Plain soap proved just as
effective. Against seemingly insuperable odds, it was more than good
enough. Plain soap was leverage.

The secret, he pointed out to me, was that the soap was more than soap. It
was a behavior-change delivery vehicle. The researchers hadn’t just handed
out Safeguard, after all. They also gave out instructions—on leaflets and in
person—explaining the six situations in which people should use it. This
was essential to the difference they made. When one looks closely at the
details of the Karachi study, one finds a striking statistic about the
households in both the test and the control neighborhoods: At the start of
the study, the average number of bars of soap households used was not zero.
It was two bars per week. In other words, they already had soap.

Sowh at did the study really change? Well, two things, Luby told me.
First, “We removed the economic restraint on purchasing soap. People say
soap is cheap and most households have soap. But we wanted people to
wash a lot. And people are quite poor. So we removed that as a barrier.”
Second, and just as important, the project managed to make soap use more
systematic.

Luby and his team had studied washing behavior in Pakistan,
Bangladesh, and other locations around South Asia, and they found that
almost everyone washes their hands after defecation. “There are strong
ideas about purity in South Asia,” he said. Even when the place to wash is
far away, people go and clean their hands over 80 percent of the time, a rate
that would put most denizens of airport bathrooms to shame. But the
washing was not very effective, the researchers found. Often people did it
too quickly. Or they cleaned just the “involved” hand. Or they used ash or
mud rather than soap and water.

The soap experiment changed that. The field-workers gave specific
instructions on hand-washing technique—on the need to wet both hands
completely, to lather well, to rinse all the soap off, even if, out of necessity,
as the published report noted, “hands were typically dried on participants’
clothing.” The instructions also got people used to washing at moments



when they weren’t used to doing so. “Before preparing food or feeding a
child is not a time when people think about washing,” Luby explained. The
soap itself was also a factor. “It was really nice soap,” he pointed out. It
smelled good and lathered better than the usual soap people bought. People
liked washing with it. “Global multinational corporations are really focused
on having a good consumer experience, which sometimes public health
people are not.” Lastly, people liked receiving the soap. The public health
field-workers were bringing them a gift rather than wagging a finger. And
with the gift came a few basic ideas that would improve their lives and
massively reduce disease.

Thinking back on the experiment, I was fascinated to realize that it was as
much a checklist study as a soap study. So I wondered: Could a checklist be
our soap for surgical care—simple, cheap, effective, and transmissible? I
still had a hard time grasping how to make a checklist that could be both
simple and effective for the manifold problems posed by surgery on a
global scale. I was uncertain that it was even possible. But several of my
colleagues were more sanguine when the idea was raised at the Geneva
meeting.

One brought up the experience of Columbus Children’s Hospital, which
had developed a checklist to reduce surgical infections. Infection is one of
the most common complications of surgery in children. And the most
effective way to prevent it, aside from using proper antiseptic technique, is
to make sure you give an appropriate antibiotic during the sixty-minute
window before the incision is made.

The timing is key. Once the incision is made, it is too late for the
antibiotic. Give it more than sixty minutes before the procedure, and the
antibiotic has worn off. But give it on time and studies show this single step
reduces the infection risk by up to half. Even if the antibiotic is squeezed
into the bloodstream only thirty seconds before the incision is made,
researchers have found, the circulation time is fast enough for the drug to
reach the tissue before the knife breaches the skin.

Yet the step is commonly missed. In 2005, Columbus Children’s Hospital
examined its records and found that more than one-third of its
appendectomy patients failed to get the right antibiotic at the right time.



Some got it too soon. Some got it too late. Some did not receive an
antibiotic at all.

It seems dumb. How hard could this be? Even people in medicine assume
we get this kind of simple task right 100 percent of the time. But in fact we
don’t. With all the flurry of things that go on when a patient is wheeled into
an operating room, this is exactly the sort of step that can be neglected. The
anesthesiologists are the ones who have to provide the antibiotic, but they
are concentrating on getting the patient safely and calmly to sleep— and
this is no small matter when that patient is a scared eight-year-old lying
naked on a cold table in a room full of strangers getting ready to cut into
her. Add in an equipment malfunction (“Is that red light supposed to be
blinking like that?”), or the patient’s asthma acting up, or a page for the
surgeon to call the emergency room, and you begin to see how something as
mundane as an antibiotic can slip past.

The hospital’s director of surgical administration, who happened to be not
only a pediatric cardiac surgeon but also a pilot, decided to take the aviation
approach. He designed a preincision “Cleared for Takeoff ” checklist that he
put on a whiteboard in each of the operating rooms. It was really simple.
There was a check box for the nurse to verbally confirm with the team that
they had the correct patient and the correct side of the body planned for
surgery—something teams are supposed to verify in any case. And there
was a further check box to confirm that the antibiotics were given (or else
judged unnecessary, which they can be for some operations).

There wasn’t much more to it. But getting teams to stop and use the
checklist—to make it their habit—was clearly tricky. A couple of check
boxes weren’t going to do much all by themselves. So the surgical director
gave some lectures to the nurses, anesthesiologists, and surgeons explaining
what this checklist thing was all about. He also did something curious: he
designed a little metal tent stenciled with the phrase Cleared for Take off
and arranged for it to be placed in the surgical instrument kits. The metal
tent was six inches long, just long enough to cover a scalpel, and the nurses
were asked to set it over the scalpel when laying out the instruments before
a case. This served as a reminder to run the checklist before making the
incision. Just as important, it also made clear that the surgeon could not
start the operation until the nurse gave the okay and removed the tent, a



subtle cultural shift. Even a modest checklist had the effect of distributing
power.

The surgical director measured the effect on care. After three months, 89
percent of appendicitis patients got the right antibiotic at the right time.
After ten months, 100 percent did. The checklist had become habitual—and
it had also become clear that team members could hold up an operation
until the necessary steps were completed.

I was intrigued. But I remained doubtful. Yes, using a checklist, this one
hospital got one aspect of care to go consistently right for surgical patients.
I was even willing to believe their surgical infection rates had fallen
significantly as a result. But to take a serious bite out of overall
complication rates, I argued, we needed an approach that would help across
the much wider range of ways in which surgery can go wrong.

Then Richard Reznick, the chairman of surgery at the University of
Toronto, spoke up. He explained that his hospital had completed a
feasibility trial using a much broader, twenty-one-item surgical checklist.
They had tried to design it, he said, to catch a whole span of potential errors
in surgical care. Their checklist had staff verbally confirm with one another
that antibiotics had been given, that blood was available if required, that
critical scans and test results needed for the operation were on hand, that
any special instruments required were ready, and so on.

The checklist also included what they called a “teambriefing.” The team
members were supposed to stop and take a moment simply to talk with one
another before proceeding—about how long the surgeon expected the
operation to take, how much blood loss everyone should be prepared for,
whether the patient had any risks or concerns the team should know about.

Reznick had never heard about the demise of Master Builders, but he had
gravitated intuitively toward the skyscraper solution— a mix of task and
communication checks to manage the problem of proliferating complexity
—and so had others, it turned out. A Johns Hopkins pancreatic surgeon
named Martin Makary showed us an eighteen-item checklist that he’d
tested with eleven surgeons for five months at his hospital. Likewise, a
group of Southern California hospitals within the Kaiser health care system
had studied a thirty-item “surgery preflight checklist” that actually predated



the Toronto and Hopkins innovations. All of them followed the same basic
design.

Surgery has, essentially, four big killers wherever it is done in the world:
infection, bleeding, unsafe anesthesia, and what can only be called the
unexpected. For the first three, science and experience have given us some
straightforward and valuable preventive measures we think we consistently
follow but don’t. These misses are simple failures—perfect for a classic
checklist. And as a result, all the researchers’ checklists included precisely
specified steps to catch them.

But the fourth killer—the unexpected—is an entirely different kind of
failure, one that stems from the fundamentally complex risks entailed by
opening up a person’s body and trying to tinker with it. Independently, each
of the researchers seemed to have realized that no one checklist could
anticipate all the pitfalls a team must guard against. So they had determined
that the most promising thing to do was just to have people stop and talk
through the case together—to be ready as a team to identify and address
each patient’s unique, potentially critical dangers.

Perhaps all this seems kind of obvious. But it represents a significant
departure from the way operations are usually conducted. Traditionally,
surgery has been regarded as an individual performance—the surgeon as
virtuoso, like a concert pianist. There’s a reason that much of the world uses
the phrase operating theater. The OR is the surgeon’s stage. The surgeon
strides under the lights and expects to start, everyone in their places, the
patient laid out asleep and ready to go.

We surgeons want to believe that we’ve evolved along with the
complexity of surgery, that we work more as teams now. But however
embarrassing it may be for us to admit, researchers have observed 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. In one survey of three hundred staff members as they exited the
operating room following a case, one out of eight reported that they were
not even sure about where the incision would be until the operation started.

Brian Sexton, a pioneering Johns Hopkins psychologist, has conducted a
number of studies that provide a stark measure of how far we are from
really performing as teams in surgery. In one, he surveyed more than a
thousand operating room staff members from hospitals in five countries—



the United States, Germany, Israel, Italy, and Switzerland—and found that
although 64 percent of the surgeons rated their operations as having high
levels of teamwork, just 39 percent of anesthesiologists, 28 percent of
nurses, and 10 percent of anesthesia residents did. Not coincidentally,
Sexton also found that one in four surgeons believed that junior team
members should not question the decisions of a senior practitioner.

The most common obstacle to effective teams, it turns out, is not the
occasional fire-breathing, scalpel-flinging, terror-inducing surgeon, though
some do exist. (One favorite example: Several years ago, when I was in
training, a senior surgeon grew incensed with one of my fellow residents for
questioning the operative plan and commanded him to leave the table and
stand in the corner until he was sorry. When he refused, the surgeon threw
him out of the room and tried to get him suspended for insubordination.)
No, the more familiar and widely dangerous issue is a kind of silent
disengagement, the consequence of specialized technicians sticking
narrowly to their domains. “That’s not my problem” is possibly the worst
thing people can think, whether they are starting an operation, taxiing an
airplane full of passengers down a runway, or building a thousand-foot-tall
skyscraper. But in medicine, we see it all the time. I’ve seen it in my own
operating room.

Teamwork may just be hard in certain lines of work. Under conditions of
extreme complexity, we inevitably rely on a division of tasks and expertise
—in the operating room, for example, there is the surgeon, the surgical
assistant, the scrub nurse, the circulating nurse, the anesthesiologist, and so
on. They can each be technical masters at what they do. That’s what we
train them to be, and that alone can take years. But the evidence suggests
we need them to see their job not just as performing their isolated set of
tasks well but also as helping the group get the best possible results. This
requires finding a way to ensure that the group lets nothing fall between the
cracks and also adapts as a team to whatever problems might arise.

I had assumed that achieving this kind of teamwork was
mostly a matter of luck. I’d certainly experienced it at times— difficult

operations in which everyone was nonetheless firing on all cylinders, acting
as one. I remember an eighty-year-old patient who required an emergency
operation. He had undergone heart surgery the week before and had been
recovering nicely. But during the night he’d developed a sudden, sharp,



unrelenting pain in his abdomen, and over the course of the morning it had
mounted steadily in severity. I was asked to see him from general surgery. I
found him lying in bed, prostrate with pain. His heart rate was over one
hundred and irregular. His blood pressure was dropping. And wherever I
touched his abdomen, the sensation made him almost leap off the bed in
agony.

He knew this was trouble. His mind was completely sharp. But he didn’t
seem scared.

“What do we need to do?” he asked between gritted teeth.
I explained that I believed his body had thrown a clot into his intestine’s

arterial supply. It was as if he’d had a stroke, only this one had cut off blood
flow to his bowel, not his brain. Without blood flow, his bowel would turn
gangrenous and rupture. This was not survivable without surgery. But, I
also had to tell him, it was often not survivable even with surgery. Perhaps
half of the patients in his circumstance make it through. If he was one of
them, there would be many complications to worry about. He might need a
ventilator or a feeding tube. He’d already been through one major
operation. He was weak and not young. I asked him if he wanted to go
ahead.

Yes, he said, but he wanted me to speak with his wife and son first. I
reached them by phone. They too said to proceed. I called the operating
room control desk and explained the situation. I needed an OR and a team
right away. I’d take whatever and whoever were available.

We got him to the OR within the hour. And as people assembled and set
to work, there was the sense of a genuine team taking form. Jay, the
circulating nurse, introduced himself to the patient and briefly explained
what everyone was doing. Steve, the scrub nurse, was already gowned and
gloved, standing by with the sterile instruments at the ready. Zhi, the senior
anesthesiologist, and Thor, his resident, were conferring, making sure they
had their plans straight, as they set out their drugs and equipment. Joaquim,
the surgery resident, stood by with a Foley catheter, ready to slip it into the
patient’s bladder as soon as he was asleep.

The clock was ticking. The longer we took, the more bowel would die.
The more bowel that died, the sicker the man would become and the lower
his chance of survival. Everyone understood this, which by itself was a lot.
People don’t always get it— really feel the urgency of the patient’s



condition. But these people did. They were swift, methodical, and in sync.
The case was far from easy, but for whatever reason, it seemed like nothing
could thwart us.

The patient was a big man with a short neck and not much lung reserve,
making it potentially difficult to place a breathing tube when Zhi sent him
off to sleep. But Zhi had warned us of the possibility of trouble and
everyone was ready with a backup plan and the instruments he and Thor
might need. When Joaquim and I opened up the patient, we found that the
right colon was black with gangrene—it had died—but it had not ruptured,
and the remaining three-fourths of the colon and all the small bowel seemed
to be okay. This was actually good news.

The problem was limited. As we began removing the right colon,
however, it became evident that the rest of the colon was not, in fact, in
good shape. Where it should have been healthy pink, we found scattered
dime- and quarter-sized patches of purple. The blood clots that had blocked
off the main artery to the right colon had also showered into the arterial
branches of the left side. We would have to remove the patient’s entire
colon, all four feet of it, and give him an ostomy—a bag for his excreted
wastes. Steve, thinking ahead, asked Jay to grab a retractor we’d need.
Joaquim nudged me to make the abdominal incision bigger, and he stayed
with me at every step, clamping, cutting, and tying as we proceeded inch by
inch through the blood vessels tethering the patient’s colon. The patient
began oozing blood from every raw surface—toxins from the gangrene
were causing him to lose his ability to clot. But Zhi and Thor kept up with
the fluid requirements and the patient’s blood pressure was actually better
halfway through than it had been at the beginning. When I mentioned that I
thought the patient would need an ICU, Zhi told me he’d already arranged it
and briefed the intensivist.

Because we’d worked as a single unit, not as separate technicians, the
man survived. We were done with the operation in little more than two
hours; his vital signs were stable; and he would leave the hospital just a few
days later. The family gave me the credit, and I wish I could have taken it.
But the operation had been symphonic, a thing of orchestral beauty.

Perhaps I could claim that the teamwork itself had been my doing. But its
origins were mysterious to me. I’d have said it was just the good fortune of
the circumstances—the accidental result of the individuals who happened to



be available for the case and their particular chemistry on that particular
afternoon. Although I operated with Zhi frequently, I hadn’t worked with
Jay or Steve in months, Joaquim in even longer. I’d worked with Thor just
once. As a group of six, we’d never before done an operation together. Such
a situation is not uncommon in hospitals of any significant size. My hospital
has forty-two operating rooms, staffed by more than a thousand personnel.
We have new nurses, technicians, residents, and physician staff almost
constantly. We’re virtually always adding strangers to our teams. As a
consequence, the level of teamwork—an unspoken but critical component
of success in surgery—is unpredictable. Yet somehow, from the moment we
six were all dropped together into this particular case, things clicked. It had
been almost criminally enjoyable.

This seemed like luck, as I say. But suppose it wasn’t. That’s what the
checklists from Toronto and Hopkins and Kaiser raised as a possibility.
Their insistence that people talk to one another about each case, at least just
for a minute before starting, was basically a strategy to foster teamwork—a
kind of team huddle, as it were. So was another step that these checklists
employed, one that was quite unusual in my experience: surgical staff
members were expected to stop and make sure that everyone knew one
another’s names.

The Johns Hopkins checklist spelled this out most explicitly. Before
starting an operation with a new team, there was a check to ensure everyone
introduced themselves by name and role: “I’m Atul Gawande, the attending
surgeon”; “I’m Jay Powers, the circulating nurse”; “I’m Zhi Xiong, the
anesthesiologist”—that sort of thing.

It felt kind of hokey to me, and I wondered how much difference this step
could really make. But it turned out to have been carefully devised. There
have been psychology studies in various fields backing up what should have
been self-evident—people who don’t know one another’s names don’t work
together nearly as well as those who do. And Brian Sexton, the Johns
Hopkins psychologist, had done studies showing the same in operating
rooms. In one, he and his research team button holed surgical staff members
outside their operating rooms and asked them two questions: how would
they rate the level of communications during the operation they had just
finished and what were the names of the other staff members on the team?



The researchers learned that about half the time the staff did not know one
another’s names. When they did, however, the communications ratings
jumped significantly.

The investigators at Johns Hopkins and elsewhere had also observed that
when nurses were given a chance to say their names and mention concerns
at the beginning of a case, they were more likely to note problems and offer
solutions. The researchers called it an “activation phenomenon.” Giving
people a chance to say something at the start seemed to activate their sense
of participation and responsibility and their willingness to speak up.

These were limited studies and hardly definitive. But the initial results
were enticing. Nothing had ever been shown to improve the ability of
surgeons to broadly reduce harm to patients aside from experience and
specialized training. Yet here, in three separate cities, teams had tried out
these unusual checklists, and each had found a positive effect.

At Johns Hopkins, researchers specifically measured their checklist’s
effect on teamwork. Eleven surgeons had agreed to try it in their cases—
seven general surgeons, two plastic surgeons, and two neurosurgeons. After
three months, the number of team members in their operations reporting
that they “functioned as a well-coordinated team” leapt from 68 percent to
92 percent.

At the Kaiser hospitals in Southern California, researchers had tested
their checklist for six months in thirty-five hundred operations. During that
time, they found that their staff ’s average rating of the teamwork climate
improved from “good” to “outstanding.” Employee satisfaction rose 19
percent. The rate of OR nurse turnover—the proportion leaving their jobs
each year—dropped from 23 percent to 7 percent. And the checklist
appeared to have caught numerous near errors. In one instance, the
preoperative briefing led the team to recognize that a vial of potassium
chloride had been switched with an antibiotic vial—a potentially lethal mix-
up. In another, the checklist led the staff to catch a paperwork error that had
them planning for a thoracotomy, an open-chest procedure with a huge
front-to-back wound, when what the patient had come in for was actually a
thoracoscopy, a videoscope procedure done through a quarter-inch incision.

At Toronto, the researchers physically observed operations for specific
evidence of impact. They watched their checklist in use in only eighteen
operations. But in ten of those eighteen, they found that it had revealed



significant problems or ambiguities—in more than one case, a failure to
give antibiotics, for example; in another, uncertainty about whether blood
was available; and in several, the kinds of unique and individual patient
problems that I would not have expected a checklist to help catch.

They reported one case, for example, involving an abdominal operation
under a spinal anesthetic. In such procedures, we need the patient to report
if he or she begins to feel even a slight twinge of pain, indicating the
anesthetic might be wearing off and require supplementation. But this
particular patient had a severe neurological condition that had left him
unable to communicate verbally. Instead, he communicated through hand
signals. Normally, we restrain the arms and hands of patients to keep them
from inadvertently reaching around the sterile drapes and touching the
surgeons or the operative field. In this instance, however, the regular routine
would have caused a serious problem, but this was not clearly recognized
by the team until just before the incision was made. That was when the
surgeon walked in, pulled on his gown and gloves, and stepped up to the
operating table. Because of the checklist, instead of taking the knife, he
paused and conferred with everyone about the plans for the operation. The
Toronto report included a transcript of the discussion.

“Are there any special anesthetic considerations?” the surgeon asked.
“Just his dysarthria,” the anesthesiologist said, referring to the patient’s

inability to speak.
The surgeon thought for a moment. “It may be difficult to gauge his

neurological function because we have these issues,” he said.
The anesthesiologist agreed. “I’ve worked out a system of hand signals

with him.”
“His arm will [need to] be accessible then—not tucked,” the surgeon

said. The anesthesiologist nodded, and the team then worked out a way to
leave the patient’s arms free but protected from reaching around or beneath
the drapes.

“My other concern is the number of people in the room,” the
anesthesiologist went on, “because noise and movement may interfere with
our ability to communicate with the patient.”

“We can request silence,” the surgeon said. Problem solved.



None of these studies was complete enough to prove that a surgical
checklist could produce what WHO was ultimately looking for—a
measurable, inexpensive, and substantial reduction in overall complications
from surgery. But by the end of the Geneva conference, we had agreed that
a safe surgery checklist was worth testing on a larger scale.

A working group took the different checklists that had been tried and
condensed them into a single one. It had three “pause points,” as they are
called in aviation—three points at which the team must stop to run through
a set of checks before proceeding. There was a pause right before the
patient is given anesthesia, one after the patient is anesthetized but before
the incision is made, and one at the end of the operation, before the patient
is wheeled out of the operating room. The working group members divvied
up the myriad checks for allergies, antibiotics, anesthesia equipment, and so
on among the different pause points. They added any other checks they
could think of that might make a difference in care. And they incorporated
the communication checks in which everyone in the operating room ensures
that they know one another’s names and has a chance to weigh in on critical
plans and concerns.

We made a decision to set up a proper pilot study of our safe surgery
checklist in a range of hospitals around the world, for which WHO
committed to providing the funds. I was thrilled and optimistic. When I
returned home to Boston, I jumped to give the checklist a try myself. I
printed it out and took it to the operating room. I told the nurses and
anesthesiologists what I’d learned in Geneva.

“So how about we try this awesome checklist?” I said. It detailed steps
for everything from equipment inspection to antibiotic administration to the
discussions we should have. The rest of the team eyed me skeptically, but
they went along. “Sure, whatever you say.” This was not the first time I’d
cooked up some cockamamie idea.

I gave the checklist to Dee, the circulating nurse, and asked her to run
through the first section with us at the right time. Fifteen minutes later, we
were about to put the patient to sleep under general anesthesia, and I had to
say, Wait, what about the checklist?

“I already did it,” Dee said. She showed me the sheet. All the boxes were
checked off.

No, no, no, I said. It’s supposed to be a verbal checklist, a team checklist.



“Where does it say that?” she asked. I looked again. She was right. It
didn’t say that anywhere.

Just try it verbally anyway, I said.
Dee shrugged and started going through the list. But some of the checks

were ambiguous. Was she supposed to confirm that everyone knew the
patient’s allergies or actually state the allergies? she asked. And after a few
minutes of puzzling our way through the list, everyone was becoming
exasperated. Even the patient started shifting around on the table.

“Is everything okay?” she asked.
Oh yes, I told her. We’re only going through our checklist. Don’t worry.
But I was getting impatient, too. The checklist was too long. It was

unclear. And past a certain point, it was starting to feel like a distraction
from the person we had on the table.

By the end of the day, we had stopped using the checklist. Forget making
this work around the world. It wasn’t even working in one operating room.



6. THE CHECKLIST FACTORY

Some time after that first miserable try, I did what I should have done
to begin with. I went to the library and pulled out a few articles on how
flight checklists are made. As great as the construction-world checklists
seemed to be, they were employed in projects that routinely take months to
complete. In surgery, minutes matter. The problemof time seemed a serious
limitation. But aviation had this challenge, too, and somehow pilots’
checklists met it.

Among the articles I found was one by Daniel Boorman from the Boeing
Company in Seattle, Washington. I gave hima call. He proved to be a
veteran pilot who’d spent the last two decades developing checklists and
flight deck controls for Boeing aircraft from the 747-400 forward. He’d
most recently been one of the technical leaders behind the flight deck
design for the new 787 Dreamliner, including its pilot controls, displays,
and system of checklists. He is among the keepers of what could be called
Boeing’s “flight philosophy.”When you get on a Boeing aircraft, there is a
theory that governs the way your cockpit crew flies that plane—what their
routines are, what they do manually, what they leave to computers, and how
they should react when the unexpected occurs. Few have had more
experience translating the theory into practice than Dan Boorman. He is the
lineal descendant of the pilots who came up with that first checklist for the
B-17 bomber three-quarters of a century ago. He has studied thousands of
crashes and near crashes over the years, and he has made a science of
averting human error.

I had a trip to Seattle coming up, and he was kind enough to agree to a
visit. So one fall day, I drove a rental car down a long flat road on the city’s
outskirts to Boeing’s headquarters. They appeared rather ordinary—a
warren of low, rectangular, institutional-looking buildings that would not be
out of place on the campus of an underfunded state college, except for the
tarmac and hangar of airplanes behind them. Boorman came out to meet me



at security. He was fifty-one, pilot-trim, in slacks and an open-collared
oxford shirt—more like an engineering professor than a company man. He
took me along a path of covered concrete sidewalks to Building 3-800,
which was as plain and functional as it sounds. A dusty display case with
yellowing pictures of guys in silver flight suits appeared not to have been
touched since the 1960s. The flight test division was a fluorescent-lit space
filled with dun-colored cubicles. We sat down in a windowless conference
room in their midst. Piles of checklist handbooks from US Airways, Delta,
United, and other airlines lay stacked against a wall.

Boorman showed me one of the handbooks. It was spiral bound, about
two hundred pages long, with numerous yellow tabs. The aviation checklist
had clearly evolved since the days of a single card for taxi, takeoff, and
landing, and I wondered how anyone could actually use this hefty volume.
As he walked me through it, however, I realized the handbook was
comprised not of one checklist but of scores of them. Each one was
remarkably brief, usually just a few lines on a page in big, easy-to-read
type. And each applied to a different situation. Taken together, they covered
a vast range of flight scenarios.

First came what pilots call their “normal” checklists—the routine lists
they use for everyday aircraft operations. There were the checks they do
before starting the engines, before pulling away from the gate, before
taxiing to the runway, and so on. In all, these took up just three pages. The
rest of the handbook consisted of the “non-normal” checklists covering
every conceivable emergency situation a pilot might run into: smoke in the
cockpit, different warning lights turning on, a dead radio, a copilot
becoming disabled, and engine failure, to name just a few. They addressed
situations most pilots never encounter in their entire careers. But the
checklists were there should they need them.

Boorman showed me the one for when the DOOR FWD CARGO
warning light goes on in midflight. This signals that the forward cargo door
is not closed and secure, which is extremely dangerous. He told me of a
1989 case he’d studied in which exactly this problem occurred. An
electrical short had caused a Boeing 747 cargo door to become unlatched
during a United Airlines flight out of Honolulu on its way to Auckland,
New Zealand, with 337 passengers on board. The plane was climbing past
twenty-two thousand feet and the cabin was pressurized to maintain oxygen



levels for the passengers. At that altitude, a loose, unlatched cargo door is a
serious hazard: if it opens enough to begin leaking air, the large pressure
difference between inside and out causes a “ring-pull” effect—an explosive
release like pulling the ring top on a shaken soda can. In the Honolulu
flight, the explosion blew out the cargo door almost instantly and took with
it several upper-deck windows and five rows of business class seats. Nine
passengers were lost at sea. Passengers in adjacent seats were held in only
by their seat belts. A flight attendant in the aisle was nearly sucked out, too,
but an alert passenger managed to grab her ankle and pin her down, inches
from the gaping hole.

The crew had had no time to prevent the catastrophe. From unlatching to
blowout and the loss of nine lives took no more than 1.5 seconds. Boeing
subsequently redesigned the electrical system for its cargo doors and—
because no latch is foolproof— installed extra latches, as well. If one fails,
the DOOR FWD CARGO light goes on and the crew has more time to
respond. There is a window of opportunity to stop a blowout. That’s where
the checklist comes in.

When a latch gives way, Boorman explained, a crew should not tinker
with the door or trust that the other latches will hold. Instead, the key is to
equalize the difference between inside and outside pressures. The more you
lower the cabin pressure, the less likely the door will explode away.

Airplanes have an easy way to lower the pressure, apparently: you hit an
emergency override switch that vents the cabin air and releases the
pressurization in about thirty seconds. This solution is problematic,
however. First, the sudden loss of pressure can be extremely uncomfortable
for passengers, particularly given the ear pain it causes. Infants fare the
worst, as their eustachian tubes haven’t developed sufficiently to adjust to
the change. Second, depressurizing a plane at an altitude of twenty or thirty
thousand feet is like dropping passengers onto the summit of Mount
Everest. The air is too thin to supply enough oxygen for the body and brain.

The United Airlines flight offered a vivid lesson in what could happen,
for the cargo door blowout instantly depressurized the plane, and once the
initial, explosive decompression was over, lack of oxygen became the prime
danger for the passengers and crew. Getting sucked into the void was no
longer the issue. Everyone was able to stay well away from the ten-by-
fifteen-foot hole. The temperature, however, plummeted to near freezing,



and the oxygen levels fell so low that the crew became light-headed and
feared losing consciousness. Sensors automatically dropped oxygen masks,
but the oxygen supply on airplanes is expected to last only ten minutes.
Moreover, the supply might not even work, which is exactly what happened
on that flight.

The cockpit voice recorder caught the events from the moment the cargo
door blew away:

CAPTAIN:What the [expletive] was that?
FIRST OFFICER: I don’t know.

The pilots notified flight control that something had gone wrong. Two
seconds later, their cabin pressure and oxygen levels were gone.

FIRST OFFICER: Put your mask on, Dave.
CAPTAIN: Yeah.
FIRST OFFICER: Honolulu Center Continental One Heavy, did you

want us to turn left did you say?
RADIO: Continental One Heavy affirmative.
FIRST OFFICER: Turning now.
CAPTAIN: I can’t get any oxygen.
FLIGHT ENGINEER:What do you want me to do now?
VOICE UNIDENTIFIED: [expletive]
FIRST OFFICER: You okay?
CAPTAIN: Yeah.
FIRST OFFICER: Are you getting oxygen? We’re not getting any

oxygen.
FLIGHT ENGINEER: No I’m not getting oxygen either.

The blast had torn out the oxygen supply lines, an investigation later found.
Only by luck did the cockpit crew maintain enough control of the plane to
descend to an altitude with sufficient oxygen levels. The pilots were then
able to turn back to the Honolulu airport. All eighteen crew and 328
terrified remaining passengers survived.

The lesson for pilots is complicated. If you’re jetting along at thirty
thousand feet and the DOOR FWD CARGO warning light goes on, yes,



eliminating the pressure differential between inside and outside to stop the
door from blowing out is a very good idea, but doing it by hitting the
emergency depressurization switch and leaving everyone short of oxygen is
not. Instead, Boorman said, the best thing to do is to make a rapid but
controlled descent to eight thousand feet or as close to it as possible. At that
height, you can safely release the plane’s inside pressure— the oxygen
levels at eight thousand feet are adequate for people to breathe. (It is the
altitude of Aspen, Colorado, after all.) And with that, the risk of a United
Airlines–style door blowout will be safely eliminated.

The DOOR FWD CARGO checklist spelled out all these steps. And
Boorman stressed how carefully it was designed for a crew to use in an
emergency. All of Boeing’s aviation checklists—the company issues over
one hundred per year, either new or revised— are put together meticulously.
Boorman’s flight operations group is a checklist factory, and the experts in
it have learned a thing or two over the years about how to make the lists
work.

There are good checklists and bad, Boorman explained. Bad checklists
are vague and imprecise. They are too long; they are hard to use; they are
impractical. They are made by desk jockeys with no awareness of the
situations in which they are to be deployed. They treat the people using the
tools as dumb and try to spell out every single step. They turn people’s
brains off rather than turn them on.

Good checklists, on the other hand, are precise. They are efficient, to the
point, and easy to use even in the most difficult situations. They do not try
to spell out everything—a checklist cannot fly a plane. Instead, they provide
reminders of only the most critical and important steps—the ones that even
the highly skilled professionals using them could miss. Good checklists are,
above all, practical.

The power of checklists is limited, Boorman emphasized. They can help
experts remember how to manage a complex process or configure a
complex machine. They can make priorities clearer and prompt people to
function better as a team. By themselves, however, checklists cannot make
anyone follow them.

I could imagine, for instance, that when the DOOR FWD CARGO
warning light goes on in a cockpit, a pilot’s first instinct might not be to



grab the checklist book. How many times, after all, does a flashing warning
light end up being a false alarm? The flight would likely have been going
smoothly. No noises. No explosion. No strange thud. Just this pesky light
flipping on. The ground crew already inspected the doors at the preflight
check and found no problem. Besides, only 1 in 500,000 flights ever suffers
an accident of any kind. So a person could be tempted to troubleshoot—
maybe have someone check the circuitry before deciding that something
might really have gone wrong.

Pilots nonetheless turn to their checklists for two reasons. First, they are
trained to do so. They learn from the beginning of flight school that their
memory and judgment are unreliable and that lives depend on their
recognizing that fact. Second, the checklists have proved their worth—they
work. However much pilots are taught to trust their procedures more than
their instincts, that doesn’t mean they will do so blindly. Aviation checklists
are by no means perfect. Some have been found confusing or unclear or
flawed. Nonetheless, they have earned pilots’ faith. Face-to-face with
catastrophe, they are astonishingly willing to turn to their checklists.

In the cockpit voice recorder transcript of the United flight from
Honolulu, for example, the pilots’ readiness to rely on procedure is striking.
The circumstances were terrifying. Debris was flying. The noise was
tremendous. Their hearts were probably racing. And they had a lot to focus
on. Beyond the immediate oxygen problem, ejected sections of fuselage had
flown into engine No. 3, on the right wing, and disabled it. Additional
debris had hit engine No. 4 and set it on fire. The outer-edge wing flaps had
been damaged. And sitting up front, trying to figure out what to do, the
cockpit crew still had no idea what had really happened. They thought a
bomb had gone off. They didn’t know the full extent of the damage, or
whether another blast might occur. They nonetheless needed to shut down
the ruined engines, notify air traffic control of the emergency, descend to a
safe altitude, determine how maneuverable the plane was, sort out which
alarms on their instrument panel they could ignore and which ones they
couldn’t, and decide whether to ditch the plane in the ocean or return to
Honolulu. The greatest test of where crew members place their trust—in
their instincts or in their procedures—is how they handle such a disaster.

So what did they do? They grabbed their checklist book:



CAPTAIN: You want me to read a checklist?
FLIGHT ENGINEER: Yeah, I got it out. When you’re ready.
CAPTAIN: Ready.

There was a lot to go through, and they had to make good choices about
what procedures to turn to first. Following their protocols, they reduced
their altitude, got the two damaged engines shut down safely, tested the
plane’s ability to land despite the wing damage, dumped fuel to lighten their
load, and successfully returned to Honolulu.

To pilots, the checklists have proved worth trusting, and that is thanks to
people like Boorman, who have learned how to make good checklists
instead of bad. Clearly, our surgery checklist had a ways to go.

When you’re making a checklist, Boorman explained, you have a number
of key decisions. You must define a clear pause point at which the checklist
is supposed to be used (unless the moment is obvious, like when a warning
light goes on or an engine fails). You must decide whether you want a DO-
CONFIRM checklist or a READ-DO checklist. With a DO-CONFIRM
checklist, he said, team members perform their jobs from memory and
experience, often separately. But then they stop. They pause to run the
checklist and confirm that everything that was supposed to be done was
done. With a READ-DO checklist, on the other hand, people carry out the
tasks as they check them off—it’s more like a recipe. So for any new
checklist created from scratch, you have to pick the type that makes the
most sense for the situation.

The checklist cannot be lengthy. A rule of thumb some use is to keep it to
between five and nine items, which is the limit of working memory.
Boorman didn’t think one had to be religious on this point.

“It all depends on the context,” he said. “In some situations you have
only twenty seconds. In others, you may have several minutes.”

But after about sixty to ninety seconds at a given pause point, the
checklist often becomes a distraction from other things. People start
“shortcutting.” Steps getmissed. So you want to keep the list short by
focusing on what he called “the killer items”—the steps that are most
dangerous to skip and sometimes overlooked nonetheless. (Data



establishing which steps are most critical and how frequently people miss
them are highly coveted in aviation, though not always available.)

The wording should be simple and exact, Boorman went on, and use the
familiar language of the profession. Even the look of the checklist matters.
Ideally, it should fit on one page. It should be free of clutter and
unnecessary colors. It should use both uppercase and lowercase text for
ease of reading. (He went so far as to recommend using a sans serif type
like Helvetica.)

To some extent, we had covered this territory in drafting our surgery
checklist. No question, it needed some trimming, and many items on the list
could be sharper and less confusing. I figured we could fix it easily. But
Boorman was adamant about one further point: nomatter how careful we
might be, nomatter how much thought we might put in, a checklist has to be
tested in the real world, which is inevitably more complicated than
expected. First drafts always fall apart, he said, and one needs to study how,
make changes, and keep testing until the checklist works consistently.

This is not easy to do in surgery, I pointed out. Not in aviation, either, he
countered. You can’t unlatch a cargo door in mid-flight and observe how a
crew handles the consequences. But that’s why they have flight simulators,
and he offered to show me one.

I tried not to seem like a kid who’d just been offered a chance to go up to
the front of the plane and see the cockpit. Sure, I said. That sounds neat.

A short stroll later, we entered an adjacent building, walked through an
ordinary-looking metal door, and came upon a strange, boxlike space
capsule. It was mounted on three massive hydraulic legs. We appeared to be
on a platform of some kind, as the capsule was on our level and the legs
went down to the floor below. Boorman led me into the thing and inside
was a complete Boeing 777-200ER cockpit. He had me climb into the
captain’s seat on the left while he took the one on the right. He showed me
how to belt myself in. The windshield was three black plasma screens, until
an assistant turned them on.

“What airport do you want?” Boorman asked. “We’ve got almost every
airport in the world loaded into the database.”

I chose the Seattle-Tacoma airport, where I’d landed the day before, and
suddenly the tarmac came up on the screens. It was amazing. We were
parked at a gate. Guys with baggage carts whizzed back and forth in front



of me. In the distance, I could see other airplanes taxiing in and out of their
gates.

Boorman walked me through our checks. Built into the wall panel on my
left was a slot for the checklist book, which I could grab at any time, but it
was just a backup. Pilots usually use an electronic checklist that appears on
the center console. He demonstrated how one goes through it, reading from
the screen.

“Oxygen,” he said and pointed to where I could confirm the supply.
“Tested, 100 percent,” I was supposed to respond.
“Flight instruments,” he said, and showed me where I could find the

heading and altimeter readings.
On our initial cockpit check, we had just four preflight items to review.

Before starting the engines, we had six more items, plus a prompt asking us
to confirm that we’d completed our “taxi and takeoff briefing”—the
discussion between pilot and copilot in which they talk through their taxi
and takeoff plans and concerns. Boorman went through it with me.

His plan, as far as I could follow, was to do a “normal” takeoff on
Runway 16L, lift off at a whole lot of knots per hour, “fly the standard
departure” to the southeast, and climb to twenty thousand feet—I think. He
also said something important sounding about the radio settings. Then he
mentioned a bunch of crazy stuff—like if we had an engine failure during
takeoff, we would power down if we were still on the ground, continue
climbing if we had one engine left, or look for a good landing site nearby if
we didn’t. I nodded sagely.

“Do you have any concerns?” he asked.
“Nope,” I said.
He started the engines, and although there were no actual engines, you

could hear them rev up, and we had to talk louder to be heard above them.
Before taxiing out to the runway, we paused again for five more checks:
whether anti-icing was necessary and completed, the autobrakes were set,
the flight controls were checked, the ground equipment was cleared, and no
warning lights were on.

The three checklists took no time at all—maybe thirty seconds each—
plus maybe a minute for the briefing. The brevity was no accident,
Boorman said. People had spent hours watching pilots try out early versions



in simulators, timing them, refining them, paring them down to their most
efficient essentials.

When he was satisfied that we were ready, he had me pull out of the gate.
I was supposed to be the pilot for this flight, believe it or not. He directed
me to push the pedal brake down hard with two feet to release it. I felt a jolt
as the plane lurched forward. I controlled the direction of the nose wheel
with a tiller on my left—a spinning metal handle that I wound forward to
turn right and backward to turn left—and the speed with the throttle
controls, three levers in the center console. I weaved like a sot at first but
got the hang of it by the time we reached the runway. I throttled back down
to idle and locked the brake with both feet to wait our turn for takeoff.
Boorman called up the Before Takeoff checklist.

“Flaps,” he said.
“Set,” I said.
This was getting to be fun. We got notification from the control tower

that we were cleared. I unlocked the brakes, again. Boorman showed me
how far to push the throttle. We began accelerating down the runway,
slowly at first, and then it felt like we were rocketing. I pressed the right
and left rudder pedals to try to keep us on the center line. Then, when he
gave me the word, I pulled back on the yoke—what I’d thought of as the
steering wheel—and felt the plane lift into the air. I don’t know how the
simulator does it, but it really did seem like we were airborne.

We rose into the clouds. I could see the city fall away below us. We
slowly climbed to twenty thousand feet. And that was when the DOOR
FWD CARGO light went on. I’d forgotten that this was the whole point of
the exercise. The first couple lines of the electronic checklist came up on
the screen, but I grabbed the paper one just so I could see the whole thing
laid out.

It was, I noticed, a READ-DO checklist—read it and do it— with only
seven lines. The page explained that the forward cargo door was not closed
and secure and that our objective was to reduce the risk of door separation.

This was just a simulation, I knew perfectly well. But I still felt my pulse
picking up. The checklist said to lower the cabin pressure partially.
Actually, what it said was, “LDG ALT selector”— which Boorman showed
me is the cabin pressure control on the overhead panel—“PULL ON and set
to 8000.” I did as instructed.



Next, the checklist said to descend to the lowest safe altitude or eight
thousand feet, whichever is higher. I pushed forward on the yoke to bring
the nose down. Boorman indicated the gauge to watch, and after a few
minutes we leveled off at eight thousand feet. Now, the checklist said, put
the air outflow switches on manual and push them in for thirty seconds to
release the remaining pressure. I did this, too. And that was it. The plane
didn’t explode. We were safe. I wanted to give Boorman a high five. This
flying thing is easy, I wanted to say.

There were, however, all kinds of steps that the checklist had not
specified—notifying the radio control tower that we had an emergency, for
example, briefing the flight attendants, determining the safest nearby airport
to land and have the cargo door inspected. I hadn’t done any of these yet.
But Boorman had. The omissions were intentional, he explained. Although
these are critical steps, experience had shown that professional pilots
virtually never fail to perform them when necessary. So they didn’t need to
be on the checklist—and in fact, he argued, shouldn’t be there.

It is common to misconceive how checklists function in complex lines of
work. They are not comprehensive how-to guides, whether for building a
skyscraper or getting a plane out of trouble. They are quick and simple tools
aimed to buttress the skills of expert professionals. And by remaining swift
and usable and resolutely modest, they are saving thousands upon
thousands of lives.

One more aviation checklist story, this one relatively recent. The incident
occurred on January 17, 2008, as British Airways Flight 38 approached
London from Beijing after almost eleven hours in the air with 152 people
aboard. The Boeing 777 was making its final descent into Heathrow airport.
It was just past noon. Clouds were thin and scattered. Visibility was more
than six miles. The wind was light, and the temperature was mild despite
the season—50 degrees Fahrenheit. The flight had been completely
uneventful to this point.

Then, at two miles from the airport, 720 feet over a residential
neighborhood, just when the plane should have accelerated slightly to level
off its descent, the engines gave out. First the right engine rolled back to
minimal power, then the left. The copilot was at the controls for the landing,



and however much he tried to increase thrust, he got nothing from the
engines. For no apparent reason, the plane had gone eerily silent.

He extended the wing flaps to make the plane glide as much as possible
and to try to hold it on its original line of approach. But the aircraft was
losing forward speed too quickly. The plane had become a 350,000-pound
stone falling out of the air. Crash investigators with Britain’s Air Accidents
Investigation Branch later determined that it was falling twenty-three feet
per second. At impact, almost a quarter mile short of the runway, the plane
was calculated to be moving at 124 miles per hour.

Only by sheer luck was no one killed, either on board or on the ground.
The plane narrowly missed crashing through the roofs of nearby homes.
Passengers in cars on the perimeter road around Heathrow saw the plane
coming down and thought they were about to be killed. Through a
coincidence of international significance, one of those cars was carrying
British prime minister Gordon Brown to his plane for his first official visit
to China. “It was just yards above our heads, almost skimming a lamppost
as the plane came in very fast and very, very low,” an aide traveling with
the prime minister told London’s Daily Mirror.

The aircraft hit a grassy field just beyond the perimeter road with what a
witness described as “an enormous bang.” The nose wheels collapsed on
impact. The rightmain landing gear separated from the aircraft, and its two
right front wheels broke away, struck the right rear fuselage, and penetrated
through the passenger compartment at rows 29 and 30. The left main
landing gear pushed up through the wing. Fourteen hundred liters of jet fuel
came pouring out. Witnesses saw sparks, but somehow the fuel did not
ignite. Although the aircraft was totaled by the blunt force of the crash, the
passengers emerged mostly unharmed— the plane had gone into a
thousand-foot ground slide that slowed its momentumand tempered the
impact. Only a dozen or so passengers required hospitalization. The worst
injury was a broken leg.

Investigators from the AAIB were on the scene within an hour trying to
piece together what had happened. Their initial reports, published one
month and then four months after the crash, were documents of frustration.
They removed the engines, fuel system, and data recorders and took them
apart piece by piece. Yet they found no engine defects whatsoever. The data
download showed that the fuel flow to the engines had reduced for some



reason, but inspection of the fuel feed lines with a boroscope—a long
fiberoptic videoscope—showed no defects or obstructions. Tests of the
valves and wiring that controlled fuel flow showed they had all functioned
properly. The fuel tanks contained no debris that could have blocked the
fuel lines.

Attention therefore turned to the fuel itself. Tests showed it to be normal
Jet A-1 fuel. But investigators, considering the flight’s path over the Arctic
Circle, wondered: could the fuel have frozen in flight, caused the crash,
then thawed before they could find a trace of it? The British Airways flight
had followed a path through territory at the border of China and Mongolia
where the recorded ambient air temperature that midwinter day was -85
degrees Fahrenheit. As the plane crossed the Ural Mountains and
Scandinavia, the recorded temperature fell to -105 degrees. These were not
considered exceptional temperatures for polar flight. Although the freezing
point for Jet A-1 fuel is -53 degrees, the dangers were thought to have been
resolved. Aircraft taking Arctic routes are designed to protect the fuel
against extreme cold, and the pilots monitor the fuel temperature constantly.
Cross-polar routes for commercial aircraft opened in February 2001, and
thousands of planes have traveled them without incident since. In fact, on
the British Airways flight, the lowest fuel temperature recorded was -29
degrees, well above the fuel’s freezing point. Furthermore, the plane was
over mild-weathered London, not the Urals, when the engines lost power.

Nonetheless, investigators remained concerned that the plane’s flight path
had played a role. They proposed an elaborate theory. Jet fuel normally has
a minor amount of water moisture in it, less than two drops per gallon.
During cold-air flights, the moisture routinely freezes and floats in the fuel
as a suspension of tiny ice crystals. This had never been considered a
significant problem. But maybe on a long, very smooth polar flight—as this
one was—the fuel flow becomes so slow that the crystals have time to
sediment and perhaps accumulate somewhere in the fuel tank. Then, during
a brief burst of acceleration, such as on the final approach, the sudden
increase in fuel flow might release the accumulation, causing blockage of
the fuel lines.

The investigators had no hard evidence for this idea. It seemed a bit like
finding a man suffocated in bed and arguing that all the oxygen molecules
had randomly jumped to the other end of the room, leaving him to die in his



sleep—possible, but preposterously unlikely. Nonetheless, the investigators
tested what would happen if they injected water directly into the fuel
system under freezing conditions. The crystals that formed, they found,
could indeed clog the lines.

Almost eight months after the crash, this was all they had for an
explanation. Everyone was anxious to do something before a similar
accident occurred. Just in case the explanation was right, the investigators
figured out some midflight maneuvers to fix the problem. When an engine
loses power, a pilot’s instinct is to increase the thrust—to rev the engine.
But if ice crystals have accumulated, increasing the fuel flow only throws
more crystals into the fuel lines. So the investigators determined that pilots
should do the opposite and idle the engine momentarily. This reduces fuel
flow and permits time for heat exchangers in the piping to melt the ice—it
takes only seconds—allowing the engines to recover. At least that was the
investigators’ best guess.

So in September 2008, the Federal Aviation Administration in the United
States issued a detailed advisory with new procedures pilots should follow
to keep ice from accumulating on polar flights and also to recover flight
control if icing nonetheless caused engine failure. Pilots across the world
were somehow supposed to learn about these findings and smoothly
incorporate them into their flight practices within thirty days. The
remarkable thing about this episode—and the reason the story is worth
telling—is that the pilots did so.

How this happened—it involved a checklist, of course—is instructive.
But first think about what happens in most lines of professional work when
a major failure occurs. To begin with, we rarely investigate our failures. Not
in medicine, not in teaching, not in the legal profession, not in the financial
world, not in virtually any other kind of work where the mistakes do not
turn up on cable news. A single type of error can affect thousands, but
because it usually touches only one person at a time, we tend not to search
as hard for explanations.

Sometimes, though, failures are investigated. We learn better ways of
doing things. And then what happens? Well, the findings might turn up in a
course or a seminar, or they might make it into a professional journal or a
textbook. In ideal circumstances, we issue some inch-thick set of guidelines



or a declaration of standards. But getting the word out is far from assured,
and incorporating the changes often takes years.

One study in medicine, for example, examined the aftermath of nine
different major treatment discoveries such as the finding that the
pneumococcus vaccine protects not only children but also adults from
respiratory infections, one of our most common killers. On average, the
study reported, it took doctors seventeen years to adopt the new treatments
for at least half of American patients.

What experts like Dan Boorman have recognized is that the reason for the
delay is not usually laziness or unwillingness. The reason is more often that
the necessary knowledge has not been translated into a simple, usable, and
systematic form. If the only thing people did in aviation was issue dense,
pages-long bulletins for every new finding that might affect the safe
operation of airplanes—well, it would be like subjecting pilots to the same
deluge of almost 700,000 medical journal articles per year that clinicians
must contend with. The information would be unmanageable.

But instead, when the crash investigators issued their bulletin—as dense
and detailed as anything we find in medicine— Boorman and his team
buckled down to the work of distilling the information into its practical
essence. They drafted a revision to the standard checklists pilots use for
polar flights. They sharpened, trimmed, and puzzled over pause points—
how are pilots to know, for instance, whether an engine is failing because of
icing instead of something else? Then his group tested the checklist with
pilots in the simulator and found problems and fixed them and tested again.

It took about two weeks for the Boeing team to complete the testing and
refinement, and then they had their checklist. They sent it to every owner of
a Boeing 777 in the world. Some airlines used the checklist as it was, but
many, if not most, went on to make their own adjustments. Just as schools
or hospitals tend to do things slightly differently, so do airlines, and they are
encouraged to modify the checklists to fit into their usual procedures. (This
customization is why, when airlines merge, among the fiercest battles is the
one between the pilots over whose checklists will be used.) Within about a
month of the recommendations becoming available, pilots had the new
checklist in their hands— or in their cockpit computers. And they used it.

How do we know? Because on November 26, 2008, the disaster almost
happened again. This time it was a Delta Air Lines flight from Shanghai to



Atlanta with 247 people aboard. The Boeing 777 was at thirty-nine
thousand feet over Great Falls, Montana, when it experienced “an
uncommanded rollback” of the right No. 2 engine—the engine, in other
words, failed. Investigation later showed that ice had blocked the fuel lines
—the icing theory was correct—and Boeing instituted a mechanical change
to keep it from happening again. But in the moment, the loss of one engine
in this way, potentially two, over the mountains of Montana could have
been catastrophic.

The pilot and copilot knew what to do, though. They got out their
checklist and followed the lessons it offered. Because they did, the engine
recovered, and 247 people were saved. It went so smoothly, the passengers
didn’t even notice.

This, it seemed to me, was something to hope for in surgery.



7. THE TEST

Back in Boston, I set my research team to work making our fledgling
surgery checklist more usable. We tried to follow the lessons from aviation.
We made it clearer. We made it speedier. We adopted mainly a DO-
CONFIRM rather than a READ-DO format, to give people greater
flexibility in performing their tasks while nonetheless having them stop at
key points to confirm that critical steps have not been overlooked. The
checklist emerged vastly improved.

Next, we tested it in a simulator, otherwise known as the conference
room on my hall way at the school of public health where I do research. We
had an assistant lie on a table. She was our patient. We assigned different
people to play the part of the surgeon, the surgical assistant, the nurses (one
scrubbed-in and one circulating), and the anesthesiologist. But we hit
problems just trying to get started.

Who, for example, was supposed to bring things to a halt and kick off the
checklist? We’d been vague about that, but it proved no small decision.
Getting everyone’s attention in an operation requires a degree of
assertiveness—a level of control—that only the surgeon routinely has.
Perhaps, I suggested, the surgeon should get things started. I got booed for
this idea. In aviation, there is a reason the “pilot not flying” starts the
checklist, someone pointed out. The “pilot flying” can be distracted by
flight tasks and liable to skip a checklist. Moreover, dispersing the
responsibility sends the message that everyone—not just the captain—is
responsible for the overall well-being of the flight and should have the
power to question the process. If a surgery checklist was to make a
difference, my colleagues argued, it needed to do likewise—to spread
responsibility and the power to question. So we had the circulating nurse
call the start.

Must nurses make written check marks? No, we decided, they didn’t have
to. This wasn’t a record-keeping procedure. We were aiming for a team



conversation to ensure that everyone had reviewed what was needed for the
case to go as well as possible.

Every line of the checklist needed tweaking. We timed each successive
version by a clock on the wall. We wanted the checks at each of the three
pause points—before anesthesia, before incision, and before leaving the OR
—to take no more than about sixty seconds, and we weren’t there yet. If we
wanted acceptance in the high-pressure environment of operating rooms,
the checklist had to be swift to use. We would have to cut some lines, we
realized—the non–killer items.

This proved the most difficult part of the exercise. An inherent tension
exists between brevity and effectiveness. Cut too much and you won’t have
enough checks to improve care. Leave too much in and the list becomes too
long to use. Furthermore, an item critical to one expert might not be critical
to another. In the spring of 2007, we reconvened our WHO group of
international experts in London to consider these questions. Not
surprisingly, the most intense disagreements flared over what should stay in
and what should come out.

European and American studies had discovered, for example, that in long
operations teams could substantially reduce patients’ risks of developing
deep venous thrombosis—blood clots in their legs that can travel to their
lungs with fatal consequences—by injecting a low dose of a blood thinner,
such as heparin, or slipping compression stockings onto their legs. But
researchers in China and India dispute the necessity, as they have reported
far lower rates of blood clots in their populations than in the West and
almost no deaths. Moreover, for poor- and middle-income countries, the
remedies—stockings or heparin—aren’t cheap. And even a slight mistake
by inexperienced practitioners administering the blood thinner could cause
a dangerous overdose. The item was dropped.

We also discussed operating room fires, a notorious problem. Surgical
teams rely on high-voltage electrical equipment, cautery devices that
occasionally arc while in use, and supplies of high-concentration oxygen—
all sometimes in close proximity. As a result, most facilities in the world
have experienced a surgical fire. These fires are terrifying. Pure oxygen can
make almost anything instantly flammable—the surgical drapes over a
patient, for instance, and even the airway tube inserted into the throat. But
surgical fires are also entirely preventable. If teams ensure there are no



oxygen leaks, keep oxygen settings at the lowest acceptable concentration,
minimize the use of alcohol-containing antiseptics, and prevent oxygen
from flowing onto the surgical field, fires will not occur. A little advance
preparation can also avert harm to patients should a fire break out—in
particular, verifying that everyone knows the location of the gas valves,
alarms, and fire extinguishers. Such steps could easily be included on a
checklist.

But compared with the big global killers in surgery, such as infection,
bleeding, and unsafe anesthesia, fire is exceedingly rare. Of the tens of
millions of operations per year in the United States, it appears only about a
hundred involve a surgical fire and vanishingly few of those a fatality. By
comparison, some 300,000 operations result in a surgical site infection, and
more than eight thousand deaths are associated with these infections. We
have done far better at preventing fires than infections. Since the checks
required to entirely eliminate fires would make the list substantially longer,
these were dropped as well.

There was nothing particularly scientific or even consistent about the
decision-making process. Operating on the wrong patient or the wrong side
of the body is exceedingly rare too. But the checks to prevent such errors
are relatively quick and already accepted in several countries, including the
United States. Such mistakes also get a lot of attention. So those checks
stayed in.

In contrast, our checks to prevent communication breakdowns tackled a
broad and widely recognized source of failure. But our approach—having
people formally introduce themselves and briefly discuss critical aspects of
a given case—was far from proven effective. Improving teamwork was so
fundamental to making a difference, however, that we were willing to leave
these measures in and give them a try.

After our London meeting, we did more small-scale testing— just one
case at a time. We had a team in London try the draft checklist and give us
suggestions, then a team in Hong Kong. With each successive round, the
checklist got better. After a certain point, it seemed we had done all we
could. We had a checklist we were ready to circulate.

The final WHO safe surgery checklist spelled out nineteen checks in all.
Before anesthesia, there are seven checks. The team members confirm that
the patient (or the patient’s proxy) has personally verified his or her identity



and also given consent for the procedure. They make sure that the surgical
site is marked and that the pulse oximeter—which monitors oxygen levels
—is on the patient and working. They check the patient’s medication
allergies. They review the risk of airway problems—the most dangerous
aspect of general anesthesia—and that appropriate equipment and
assistance for them are available. And lastly, if there is a possibility of
losing more than half a liter of blood (or the equivalent for a child), they
verify that necessary intravenous lines, blood, and fluids are ready.

After anesthesia, but before incision, come seven more checks. The team
members make sure they’ve been introduced by name and role. They
confirm that everyone has the correct patient and procedure (including
which side of the body—left versus right) in mind. They confirm that
antibiotics were either given on time or were unnecessary. They check that
any radiology images needed for the operation are displayed. And to make
sure everyone is briefed as a team, they discuss the critical aspects of the
case: the surgeon reviews how long the operation will take, the amount of
blood loss the team should prepare for, and anything else people should be
aware of; the anesthesia staff review their anesthetic plans and concerns;
and the nursing staff review equipment availability, sterility, and their
patient concerns.

Finally, at the end of the operation, before the team wheels the patient
from the room, come five final checks. The circulating nurse verbally
reviews the recorded name of the completed procedure for accuracy, the
labeling of any tissue specimens going to the pathologist, whether all
needles, sponges, and instruments have been accounted for, and whether
any equipment problems need to be addressed before the next case.
Everyone on the team also reviews aloud their plans and concerns for the
patient’s recovery after surgery, to ensure information is complete and
clearly transmitted.

Operations require many more than nineteen steps, of course. But like
builders, we tried to encompass the simple to the complex, with several
narrowly specified checks to ensure stupid stuff isn’t missed (antibiotics,
allergies, the wrong patient) and a few communication checks to ensure
people work as a team to recognize the many other potential traps and
subtleties. At least that was the idea. But would it work and actually make a
measurable difference in reducing harm to patients? That was the question.



To find the answer, we decided to study the effect of the safe surgery
checklist on patient care in eight hospitals around the world. This number
was large enough to provide meaningful results while remaining
manageable for my small research team and the modest budget WHO
agreed to furnish. We got dozens of applications from hospitals seeking to
participate. We set a few criteria for selection. The hospital’s leader had to
speak English— we could translate the checklist for staff members but we
didn’t have the resources for daily communication with eight site leaders in
multiple languages. The location had to be safe for travel. We received, for
instance, an enthusiastic application from the chief of surgery in an Iraqi
hospital, which would have been fascinating, but conducting a research trial
in a war zone seemed unwise.

I also wanted a wide diversity of participating hospitals— hospitals in
rich countries, poor countries, and in between. This insistence caused a
degree of consternation at WHO headquarters. As officials explained,
WHO’s first priority is, quite legitimately, to help the poorer parts of the
world, and the substantial costs of paying for data collection in wealthier
countries would divert resources from elsewhere. But I had seen surgery in
places ranging from rural India to Harvard and seen failure across the span.
I thought the checklist might make a difference anywhere. And if it worked
in high-income countries, that success might help persuade poorer facilities
to take it up. So we agreed to include wealthier sites if they agreed to
support most, if not all, the research costs themselves.

Lastly, the hospitals had to be willing to allow observers to measure their
actual rates of complications, deaths, and systems failures in surgical care
before and after adopting the checklist. Granting this permission was no
small matter for hospitals. Most—even those in the highest income settings
—have no idea of their current rates. Close observation was bound to
embarrass some. Nonetheless, we got eight willing hospitals lined up from
all over the globe.

Four were in high-income countries and among the leading hospitals in
the world: the University of Washington Medical Center in Seattle, Toronto
General Hospital in Canada, St. Mary’s Hospital in London, and Auckland
City Hospital, New Zealand’s largest. Four were intensely busy hospitals in
low- or middle-income countries: Philippines General Hospital in Manila,
which was twice the size of the wealthier hospitals we enrolled; Prince



Hamza Hospital in Amman, Jordan, a new government facility built to
accommodate Jordan’s bursting refugee population; St. Stephen’s Hospital
in New Delhi, an urban charity hospital; and St. Francis Designated District
Hospital in Ifakara, Tanzania, the lone hospital serving a rural population of
nearly one million people.

This was an almost ridiculous range of hospitals to study. Annual health
care spending in the high-income countries reached thousands of dollars per
person, while in India, the Philippines, and East Africa, it did not rise
beyond the double digits. So, for example, the budget of the University of
Washington Medical Center—over one billion dollars per year—was more
than twice that of the entire country of Tanzania. Surgery therefore differed
starkly in our eight hospitals. On one end of the spectrum were those with
state-of-the-art capabilities allowing them to do everything from robotic
prostatectomies to liver transplants, along with factory loads of planned,
low-risk, often day-surgery procedures like hernia repairs, breast biopsies,
and ear-tube placements for drainage of chronic ear infections in children.
On the other end were hospitals forced by lack of staff and resources to
prioritize urgent operations—emergency cesarean sections for mothers
dying in childbirth, for example, or procedures for repair of severe
traumatic injuries. Even when the hospitals did the same operations—an
appendectomy, a mastectomy, the placement of a rod in a broken femur—
the conditions were so disparate that the procedures were the same only in
name. In the poorer hospitals, the equipment was meager, the teams’
training was more limited, and the patients usually arrived sicker—the
appendix having ruptured, the breast cancer having grown twice as large,
the femur proving not only broken but infected.

Nonetheless, we went ahead with our eight institutions. The goal, after
all, was not to compare one hospital with another but to determine where, if
anywhere, the checklist could improve care. We hired local research
coordinators for the hospitals and trained themto collect accurate
information on deaths and complications. We were conservative about what
counted. The complications had to be significant—a pneumonia, a heart
attack, bleeding requiring a return to the operating room or more than four
units of blood, a documented wound infection, or the like. And the
occurrence had to actually be witnessed in the hospital, not reported from
elsewhere.



We collected data on the surgical care in up to four operating rooms at
each facility for about three months before the checklist went into effect. It
was a kind of biopsy of the care received by patients across the range of
hospitals in the world. And the results were sobering.

Of the close to four thousand adult surgical patients we followed, more
than four hundred developed major complications resulting from surgery.
Fifty-six of them died. About half the complications involved infections.
Another quarter involved technical failures that required a return trip to the
operating room to stop bleeding or repair a problem. The overall
complication rates ranged from 6 percent to 21 percent. It’s important to
note that the operating rooms we were studying tended to handle the
hospital’s more complex procedures. More straightforward operations have
lower injury rates. Nonetheless, the pattern confirmed what we’d
understood: surgery is risky and dangerous wherever it is done.

We also found, as we suspected we would, signs of substantial
opportunity for improvement everywhere. None of the hospitals, for
example, had a routine approach to ensure that teams had identified, and
prepared for, cases with high blood-loss risk, or conducted any kind of
preoperative team briefing about patients. We tracked performance of six
specific safety steps: the timely delivery of antibiotics, the use of a working
pulse oximeter, the completion of a formal risk assessment for placing an
airway tube, the verbal confirmation of the patient’s identity and procedure,
the appropriate placement of intravenous lines for patients who develop
severe bleeding, and finally a complete accounting of sponges at the end of
the procedure. These are basics, the surgical equivalent of unlocking the
elevator controls before airplane takeoff. Nevertheless, we found gaps
everywhere. The very best missed at least one of these minimum steps 6
percent of the time—once in every sixteen patients. And on average, the
hospitals missed one of them in a startling two-thirds of patients, whether in
rich countries or poor. That is how flawed and inconsistent surgical care
routinely is around the world.

Then, starting in spring 2008, the pilot hospitals began implementing our
two-minute, nineteen-step surgery checklist. We knew better than to think
that just dumping a pile of copies in their operating rooms was going to
change anything. The hospital leaders committed to introducing the concept



systematically. They made presentations not only to their surgeons but also
to their anesthetists, nurses, and other surgical personnel.

We supplied the hospitals with their failure data so the staff could see
what they were trying to address. We gave them some PowerPoint slides
and a couple of YouTube videos, one demonstrating “How to Use the Safe
Surgery Checklist” and one—a bit more entertaining—entitled “How Not to
Use the Safe Surgery Checklist,” showing how easy it is to screw
everything up.

We also asked the hospital leaders to introduce the checklist in just one
operating room at first, ideally in procedures the chief surgeon was doing
himself, with senior anesthesia and nursing staff taking part. There would
surely be bugs to work out. Each hospital would have to adjust the order
and wording of the checklist to suit its particular practices and terminology.
Several were using translations. A few had already indicated they wanted to
add extra checks. For some hospitals, the checklist would also compel
systemic changes—for example, stocking more antibiotic supplies in the
operating rooms. We needed the first groups using the checklist to have the
seniority and patience to make the necessary modifications and not dismiss
the whole enterprise.

Using the checklist involved a major cultural change, as well—a shift in
authority, responsibility, and expectations about care—and the hospitals
needed to recognize that. We gambled that their staff would be far more
likely to adopt the checklist if they saw their leadership accepting it from
the outset.

My team and I hit the road, fanning out to visit the pilot sites as the
checklist effort got under way. I had never seen surgery performed in so
many different kinds of settings. The contrasts were even starker than I had
anticipated and the range of problems was infinitely wider.

In Tanzania, the hospital was two hundred miles of sometimes one-lane
dirt roads from the capital, Dar es Salaam, and flooding during the rainy
season cut off supplies—such as medications and anesthetic gases—often
for weeks at a time. There were thousands of surgery patients, but just five
surgeons and four anesthesia staff. None of the anesthetists had a medical
degree. The patients’ families supplied most of the blood for the blood
bank, and when that wasn’t enough, staff members rolled up their sleeves.



They conserved anesthetic supplies by administering mainly spinal
anesthesia—injections of numbing medication directly into the spinal canal.
They could do operations under spinal that I never conceived of. They
saved and resterilized their surgical gloves, using them over and over until
holes appeared. They even made their own surgical gauze, the nurses and
anesthesia staff sitting around an old wood table at teatime each afternoon
cutting bolts of white cotton cloth to size for the next day’s cases.

In Delhi, the charity hospital was not as badly off as the Tanzanian site or
hospitals I’d been to in rural India. There were more supplies. The staff
members were better trained. But the volume of patients they were asked to
care for in this city of thirteen million was beyond comprehension. The
hospital had seven fully trained anesthetists, for instance, but they had to
perform twenty thousand operations a year. To provide a sense of how
ludicrous this is, our New Zealand pilot hospital employed ninety-two
anesthetists to manage a similar magnitude of surgery. Yet, for all the
equipment shortages, power outages, waiting lists, fourteen-hour days, I
heard less unhappiness and complaining from the surgical staff in Delhi
than in many American hospitals I’ve been to.

The differences were not just between rich and poor settings, either. Each
site was distinctive. St. Mary’s Hospital, for example, our London site, was
a compound of red brick and white stone buildings more than century and a
half old, sprawling over a city block in Paddington. Alexander Fleming
discovered penicillin here in 1928. More recently, under its chairman of
surgery, Lord Darzi of Denham, the hospital has become an international
pioneer in the development of minimally invasive surgery and surgical
simulation. St. Mary’s is modern, well equipped, and a draw for London’s
powerful and well-to-do—Prince William and Prince Harry were born here,
for example, and Conservative Party leader David Cameron’s severely
disabled son was cared for here, as well. But it is hardly posh. It remains a
government hospital in the National Health Service, serving any Briton
without charge or distinction.

Walking through St. Mary’s sixteen operating rooms, I found they looked
much the same as the ones where I work in Boston— high-tech, up-to-date.
But surgical procedures seemed different at every stage. The patients were
put to sleep outside the operating theater, instead of inside, and then
wheeled in, which meant that the first part of the checklist would have to be



changed. The anesthetists and circulating nurses didn’t wear masks, which
seemed like sacrilege to me, although I had to admit their necessity is
unproven for staff who do not work near the patient’s incision. Almost
every term the surgical teams used was unfamiliar. We all supposedly spoke
English, but I was often unsure what they were talking about.

In Jordan, the working environment was also at once recognizable and
alien, but in a different way. The operating rooms in Amman had zero frills
—this was a still-developing country and the equipment was older and
heavily used—but they had most of the things I am used to as a surgeon,
and the level of care seemed very good. One of the surgeons I met was
Iraqi. He’d trained in Baghdad and practiced there until the chaos following
the American invasion in 2003 forced him to flee with his family,
abandoning their home, their savings, and his work. Before Saddam
Hussein, in the last years of his rule, gutted the Iraqi medical system,
Baghdad had provided some of the best medical care in the Middle East.
But, the surgeon said, Jordan now seemed positioned to take that role and
he felt fortunate to be there. I learned that more than 200,000 foreign
patients travel to Jordan for their health care each year, generating as much
as one billion dollars in revenues for the country.

What I couldn’twork out, though, was how the country’s strict gender
divide was negotiated in its operating rooms. I remember sitting outside a
restaurant the day I arrived, studying the people passing by. Men and
women were virtually always separated. Most women covered their hair. I
got to know one of the surgery residents, a young man in his late twenties
who was my guide for the visit. We even went out to see a movie together.
When I learned he had a girlfriend of two years, a graduate student, I asked
him how long it was before he got to see her hair.

“I never have,” he said.
“C’mon. Never?”
“Never.” He’d seen a few strands. He knew she had dark brown hair. But

even in the more modern dating relationship of a partly Westernized, highly
educated couple, that was it.

In the operating rooms, all the surgeons were men. Most of the nurses
were women. The anesthetists split half and half. Given the hierarchies, I
wondered whether the kind of teamwork envisioned by the checklist was
even possible. The women wore their head scarves in the operating rooms.



Most avoided eye contact with men. I slowly learned, however, that not all
was what it seemed. The staff didn’t hesitate to discard the formalities when
necessary. I saw a gallbladder operation in which the surgeon inadvertently
contaminated his glove while adjusting the operating lights. He hadn’t
noticed. But the nurse had.

“You have to change your glove,” the nurse told him in Arabic.
(Someone translated for me.)

“It’s fine,” the surgeon said.
“No, it’s not,” the nurse said. “Don’t be stupid.” Then she made him

change his glove.
For all the differences among the eight hospitals, I was nonetheless

surprised by how readily one could feel at home in an operating room,
wherever it might be. Once a case was under way, it was still surgery. You
still had a human being on the table, with his hopes and his fears and his
body opened up to you, trusting you to do right by him. And you still had a
group of people striving to work together with enough skill and
commitment to warrant that trust.

The introduction of the checklist was rocky at times. We had our share of
logistical hiccups. In Manila, for instance, it turned out there was only one
nurse for every four operations, because qualified operating nurses kept
getting snapped up by American and Canadian hospitals. The medical
students who filled in were often too timid to start the checklist, so the
anesthesia staff had to be persuaded to take on the task. In Britain, the local
staff had difficulties figuring out the changes needed to accommodate their
particular anesthesia practices.

There was a learning curve, as well. However straightforward the
checklist might appear, if you are used to getting along without one,
incorporating it into the routine is not always a smooth process. Sometimes
teams forgot to carry out part of the checklist— especially the sign-out,
before taking the patient from the room. Other times they found adhering to
it just too hard—though not because doing so was complicated. Instead, the
difficulty seemed to be social. It felt strange to people just to get their
mouths around the words—for a nurse to say, for example, that if the
antibiotics hadn’t been given, then everyone needed to stop and give them
before proceeding. Each person has his or her style in the operating room,
especially surgeons. Some are silent, some are moody, some are chatty.



Very few knew immediately how to adapt their style to huddling with
everyone—even the nursing student—for a systematic run-through of the
plans and possible issues.

The introduction of names and roles at the start of an operating day
proved a point of particularly divided view. From Delhi to Seattle, the
nurses seemed especially grateful for the step, but the surgeons were
sometimes annoyed by it. Nonetheless, most complied.

Most but not all. We were thrown out of operating rooms all over the
world. “This checklist is a waste of time,” we were told. In a couple places,
the hospital leaders wanted to call the curmudgeons on the carpet and force
them to use it. We discouraged this. Forcing the obstinate few to adopt the
checklist might cause a backlash that would sour others on participating.
We asked the leaders to present the checklist as simply a tool for people to
try in hopes of improving their results. After all, it remained possible that
the detractors were right, that the checklist would prove just another well-
meaning effort with no significant effect whatsoever.

Pockets of resistance notwithstanding, the safe surgery checklist effort
was well under way within a month in each location, with teams regularly
using the checklist in every operating room we were studying. We
continued monitoring the patient data. I returned home to wait out the
results.

I was nervous about the project. We had planned to examine the results for
only a short time period, about three months in each pilot site after
introduction of the checklist. That way any changes we observed would
likely be the consequence of the checklist and not of long-term, ongoing
trends in health or medical care. But I worried whether anything could
really change in so short a time. The teams were clearly still getting the
hang of things. Perhaps we hadn’t given them enough time to learn. I also
worried about how meager the intervention was when you got right down to
it. We’d provided no new equipment, staff, or clinical resources to hospitals.
The poor places were still poor, and we had to wonder whether
improvement in their results was really possible without changing that. All
we’d done was give them a one-page, nineteen-item list and shown them
how to use it. We’d worked hard to make it short and simple, but perhaps



we’d made it too short and too simple—not detailed enough. Maybe we
shouldn’t have listened to the aviation gurus.

We began to hear some encouraging stories, however. In London, during
a knee replacement by an orthopedic surgeon who was one of our toughest
critics, the checklist brought the team to recognize, before incision and the
point of no return, that the knee prosthesis on hand was the wrong size for
the patient—and that the right size was not available in the hospital. The
surgeon became an instant checklist proponent.

In India, we learned, the checklist led the surgery department to
recognize a fundamental flaw in its system of care. Usual procedure was to
infuse the presurgery antibiotic into patients in the preoperative waiting area
before wheeling them in. But the checklist brought the clinicians to realize
that frequent delays in the operating schedule meant the antibiotic had
usually worn off hours before incision. So the hospital staff shifted their
routine in line with the checklist and waited to give the antibiotic until
patients were in the operating room.

In Seattle, a friend who had joined the surgical staff at the University of
Washington Medical Center told me how easily the checklist had fit into her
operating room’s routine. But was it helping them catch errors, I asked?

“No question,” she said. They’d caught problems with antibiotics,
equipment, overlooked medical issues. But more than that, she thought
going through the checklist helped the staff respond better when they ran
into trouble later—like bleeding or technical difficulties during the
operation. “We just work better together as a team,” she said.

The stories gave me hope.

In October 2008, the results came in. I had two research fellows, both of
them residents in general surgery, working on the project with me. Alex
Haynes had taken more than a year away from surgical training to run the
eight-city pilot study and compile the data. Tom Weiser had spent two years
managing development of the WHO checklist program, and he’d been in
charge of double-checking the numbers. A retired cardiac surgeon, William
Berry, was the triple check on everything they did. Late one afternoon, they
all came in to see me.

“You’ve got to see this,” Alex said.



He laid a sheaf of statistical printouts in front of me and walked me
through the tables. The final results showed that the rate of major
complications for surgical patients in all eight hospitals fell by 36 percent
after introduction of the checklist. Deaths fell 47 percent. The results had
far outstripped what we’d dared to hope for, and all were statistically highly
significant. Infections fell by almost half. The number of patients having to
return to the operating room after their original operations because of
bleeding or other technical problems fell by one-fourth. Overall, in this
group of nearly 4,000 patients, 435 would have been expected to develop
serious complications based on our earlier observation data. But instead just
277 did. Using the checklist had spared more than 150 people from harm—
and 27 of them from death.

You might think that I’d have danced a jig on my desk, that I’d have gone
running through the operating room hallways yelling, “It worked! It
worked!” But this is not what I did. Instead, I became very, very nervous. I
started poking through the pile of data looking for mistakes, for problems,
for anything that might upend the results.

Suppose, I said, this improvement wasn’t due to the checklist. Maybe,
just by happenstance, the teams had done fewer emergency cases and other
risky operations in the second half of the study, and that’s why their results
looked better. Alex went back and ran the numbers again. Nope, it turned
out. The teams had actually done slightly more emergency cases in the
checklist period than before. And the mix of types of operations— obstetric,
thoracic, orthopedic, abdominal—was unchanged.

Suppose this was just a Hawthorne effect, that is to say, a byproduct of
being observed in a study rather than proof of the checklist’s power. In
about 20 percent of the operations, after all, a researcher had been
physically present in the operating room collecting information. Maybe the
observer’s presence was what had improved care. The research team
pointed out, however, that the observers had been in the operating rooms
from the very beginning of the project, and the results had not leaped
upward until the checklist was introduced. Moreover, we’d tracked which
operations had an observer and which ones hadn’t. And when Alex
rechecked the data, the results proved no different—the improvements were
equally dramatic for observed and unobserved operations.



Okay, maybe the checklist made a difference in some places, but perhaps
only in the poor sites. No, that didn’t turn out to be the case either. The
baseline rate of surgical complications was indeed lower in the four
hospitals in high-income countries, but introducing the checklist had
produced a one-third decrease in major complications for the patients in
those hospitals, as well— also a highly significant reduction.

The team took me through the results for each of the eight hospitals, one
by one. In every site, introduction of the checklist had been accompanied by
a substantial reduction in complications. In seven out of eight, it was a
double-digit percentage drop. This thing was real.

In January 2009, the New England Journal of Medicine published our
study as a rapid-release article. Even before then, word began to leak out as
we distributed the findings to our pilot sites. Hospitals in Washington State
learned of Seattle’s results and began trying the checklist themselves. Pretty
soon they’d formed a coalition with the state’s insurers, Boeing, and the
governor to systematically introduce the checklist across the state and track
detailed data. In Great Britain, Lord Darzi, the chairman of surgery at St.
Mary’s Hospital, had meanwhile been made a minister of health. When he
and the country’s top designate to WHO, Sir Liam Donaldson (who had
also pushed for the surgery project in the first place), saw the study results,
they launched a campaign to implement the checklist nationwide.

The reaction of surgeons was more mixed. Even if using the checklist
didn’t take the time many feared—indeed, in several hospitals teams
reported that it saved them time—some objected that the study had not
clearly established how the checklist was producing such dramatic results.
This was true. In our eight hospitals, we saw improvements in
administering antibiotics to reduce infections, in use of oxygen monitoring
during operations, in making sure teams had the right patient and right
procedure before making an incision. But these particular improvements
could not explain why unrelated complications like bleeding fell, for
example. We surmised that improved communication was the key. Spot
surveys of random staff members coming out of surgery after the checklist
was in effect did indeed report a significant increase in the level of
communication. There was also a notable correlation between teamwork



scores and results for patients— the greater the improvement in teamwork,
the greater the drop in complications.

Perhaps the most revealing information, however, was simply what the
staff told us. More than 250 staff members—surgeons, anesthesiologists,
nurses, and others—filled out an anonymous survey after three months of
using the checklist. In the beginning, most had been skeptical. But by the
end, 80 percent reported that the checklist was easy to use, did not take a
long time to complete, and had improved the safety of care. And 78 percent
actually observed the checklist to have prevented an error in the operating
room.

Nonetheless, some skepticism persisted. After all, 20 percent did not find
it easy to use, thought it took too long, and felt it had not improved the
safety of care.

Then we asked the staff one more question. “If you were having an
operation,” we asked, “would you want the checklist to be used?”

A full 93 percent said yes.



8. THE HERO IN THE AGE OF CHECKLISTS

We have an opportunity before us, not just in medicine but in virtually
any endeavor. Even the most expert among us can gain from searching out
the patterns of mistakes and failures and putting a few checks in place. But
will we do it? Are we ready to grab onto the idea? It is far from clear.

Take the safe surgery checklist. If someone discovered a new drug that
could cut down surgical complications with anything remotely like the
effectiveness of the checklist, we would have television ads with minor
celebrities extolling its virtues. Detail men would offer free lunches to get
doctors to make it part of their practice. Government programs would
research it. Competitors would jump in to make newer and better versions.
If the checklist were a medical device, we would have surgeons clamoring
for it, lining up at display booths at surgical conferences to give it a try,
hounding their hospital administrators to get one for them—because, damn
it, doesn’t providing good care matter to those pencil pushers?

That’s what happened when surgical robots came out—drool-inducing
twenty-second-century $1.7 million remote-controlled machines designed
to help surgeons do laparoscopic surgery with more maneuverability inside
patients’ bodies and fewer complications. The robots increased surgical
costs massively and have so far improved results only modestly for a few
operations, compared with standard laparoscopy. Nonetheless, hospitals in
the United States and abroad have spent billions of dollars on them.

But meanwhile, the checklist? Well, it hasn’t been ignored. Since the
results of the WHO safe surgery checklist were made public, more than a
dozen countries—including Australia, Brazil, Canada, Costa Rica, Ecuador,
France, Ireland, Jordan, New Zealand, the Philippines, Spain, and the
United Kingdom—have publicly committed to implementing versions of it
in hospitals nationwide. Some are taking the additional step of tracking
results, which is crucial for ensuring the checklist is being put in place
successfully. In the United States, hospital associations in twenty states



have pledged to do the same. By the end of 2009, about 10 percent of
American hospitals had either adopted the checklist or taken steps to
implement it, and worldwide more than two thousand hospitals had.

This is all encouraging. Nonetheless, we doctors remain a long way from
actually embracing the idea. The checklist has arrived in our operating
rooms mostly from the outside in and from the top down. It has come from
finger-wagging health officials, who are regarded by surgeons as more or
less the enemy, or from jug-eared hospital safety officers, who are about as
beloved as the playground safety patrol. Sometimes it is the chief of surgery
who brings it in, which means we complain under our breath rather than
raise a holy tirade. But it is regarded as an irritation, as interference on our
terrain. This is my patient. This is my operating room. And the way I carry
out an operation is my business and my responsibility. So who do these
people think they are, telling me what to do?

Now, if surgeons end up using the checklist anyway, what is the big deal
if we do so without joy in our souls? We’re doing it. That’s what matters,
right?

Not necessarily. Just ticking boxes is not the ultimate goal here.
Embracing a culture of teamwork and discipline is. And if we recognize the
opportunity, the two-minute WHO checklist is just a start. It is a single,
broad-brush device intended to catch a few problems common to all
operations, and we surgeons could build on it to do even more. We could
adopt, for example, specialized checklists for hip replacement procedures,
pancreatic operations, aortic aneurysm repairs, examining each of our major
procedures for their most common avoidable glitches and incorporating
checks to help us steer clear of them. We could even devise emergency
checklists, like aviation has, for nonroutine situations— such as the cardiac
arrest my friend John described in which the doctors forgot that an overdose
of potassium could be a cause.

Beyond the operating room, moreover, there are hundreds, perhaps
thousands, of things doctors do that are as dangerous and prone to error as
surgery. Take, for instance, the treatment of heart attacks, strokes, drug
overdoses, pneumonias, kidney failures, seizures. And consider the many
other situations that are only seemingly simpler and less dire—the
evaluation of a patient with a headache, for example, a funny chest pain, a
lung nodule, a breast lump. All involve risk, uncertainty, and complexity—



and therefore steps that are worth committing to a checklist and testing in
routine care. Good checklists could become as important for doctors and
nurses as good stethoscopes (which, unlike checklists, have never been
proved to make a difference in patient care). The hard question—still
unanswered—is whether medical culture can seize the opportunity.

Tom Wolfe’s The Right Stuff tells the story of our first astronauts and
charts the demise of the maverick, Chuck Yeager test-pilot culture of the
1950s. It was a culture defined by how unbelievably dangerous the job was.
Test pilots strapped themselves into machines of barely controlled power
and complexity, and a quarter of them were killed on the job. The pilots had
to have focus, daring, wits, and an ability to improvise—the right stuff. But
as knowledge of how to control the risks of flying accumulated—as
checklists and flight simulators became more prevalent and sophisticated—
the danger diminished, values of safety and conscientiousness prevailed,
and the rock star status of the test pilots was gone.

Something like this is going on in medicine. We have the means to make
some of the most complex and dangerous work we do—in surgery,
emergency care, ICU medicine, and beyond— more effective than we ever
thought possible. But the prospect pushes against the traditional culture of
medicine, with its central belief that in situations of high risk and
complexity what you want is a kind of expert audacity—the right stuff,
again. Checklists and standard operating procedures feel like exactly the
opposite, and that’s what rankles many people.

It’s ludicrous, though, to suppose that checklists are going to do away
with the need for courage, wits, and improvisation. The work of medicine is
too intricate and individual for that: good clinicians will not be able to
dispense with expert audacity. Yet we should also be ready to accept the
virtues of regimentation.

And it is true well beyond medicine. The opportunity is evident in many
fields—and so also is the resistance. Finance offers one example. Recently,
I spoke to Mohnish Pabrai, managing partner in Pabrai Investment Funds in
Irvine, California. He is one of three investors I’ve recently met who have
taken a page from medicine and aviation to incorporate formal checklists
into their work. All three are huge investors: Pabrai runs a $500 million
portfolio; Guy Spier is head of Aquamarine Capital Management in Zurich,



Switzerland, a $70 million fund. The third did not want to be identified by
name or to reveal the size of the fund where he is a director, but it is one of
the biggest in the world and worth billions. The three consider themselves
“value investors”—investors who buy shares in under recognized,
undervalued companies. They don’t time the market. They don’t buy
according to some computer algorithm. They do intensive research, look for
good deals, and invest for the long run. They aim to buy Coca-Cola before
everyone realizes it’s going to be Coca-Cola.

Pabrai described what this involves. Over the last fifteen years, he’s made
a new investment or two per quarter, and he’s found it requires in-depth
investigation of ten or more prospects for each one he finally buys stock in.
The ideas can bubble up from anywhere—a billboard advertisement, a
newspaper article about real estate in Brazil, a mining journal he decides to
pick up for some random reason. He reads broadly and looks widely. He has
his eyes open for the glint of a diamond in the dirt, of a business about to
boom.

He hits upon hundreds of possibilities but most drop away after cursory
examination. Every week or so, though, he spots one that starts his pulse
racing. It seems surefire. He can’t believe no one else has caught onto it yet.
He begins to think it could make him tens of millions of dollars if he plays
it right, no, this time maybe hundreds of millions.

“You go into greed mode,” he said. Guy Spier called it “cocaine brain.”
Neuroscientists have found that the prospect of making money stimulates
the same primitive reward circuits in the brain that cocaine does. And that,
Pabrai said, is when serious investors like himself try to become systematic.
They focus on dispassionate analysis, on avoiding both irrational
exuberance and panic. They pore over the company’s financial reports,
investigate its liabilities and risks, examine its management team’s track
record, weigh its competitors, consider the future of the market it is in—
trying to gauge both the magnitude of opportunity and the margin of safety.

The patron saint of value investors is Warren Buffett, among the most
successful financiers in history and one of the two richest men in the world,
even after the losses he suffered in the crash of 2008. Pabrai has studied
every deal Buffett and his company, Berkshire Hathaway, have made—
good or bad—and read every book he could find about them. He even
pledged $650,000 at a charity auction to have lunch with Buffett.



“Warren,” Pabrai said—and after a $650,000 lunch, I guess first names
are in order—“Warren uses a ‘mental checklist’ process” when looking at
potential investments. So that’s more or less what Pabrai did from his fund’s
inception. He was disciplined. He made sure to take his time when studying
a company. The process could require weeks. And he did very well
following this method—but not always, he found. He also made mistakes,
some of them disastrous.

These were not mistakes merely in the sense that he lost money on his
bets or missed making money on investments he’d rejected. That’s bound to
happen. Risk is unavoidable in Pabrai’s line of work. No, these were
mistakes in the sense that he had miscalculated the risks involved, made
errors of analysis. For example, looking back, he noticed that he had
repeatedly erred in determining how “leveraged” companies were—how
much cash was really theirs, how much was borrowed, and how risky those
debts were. The information was available; he just hadn’t looked for it
carefully enough.

In large part, he believes, the mistakes happened because he wasn’t able
to damp down the cocaine brain. Pabrai is a forty-five-year-old former
engineer. He comes from India, where he clawed his way up its fiercely
competitive educational system. Then he secured admission to Clemson
University, in South Carolina, to study engineering. From there he climbed
the ranks of technology companies in Chicago and California. Before going
into investment, he built a successful informational technology company of
his own. All this is to say he knows a thing or two about being
dispassionate and avoiding the lure of instant gratification. Yet no matter
how objective he tried to be about a potentially exciting investment, he said,
he found his brain working against him, latching onto evidence that
confirmed his initial hunch and dismissing the signs of a downside. It’s
what the brain does.

“You get seduced,” he said. “You start cutting corners.”
Or, in the midst of a bear market, the opposite happens. You go into “fear

mode,” he said. You see people around you losing their bespoke shirts, and
you overestimate the dangers.

He also found he made mistakes in handling complexity. A good decision
requires looking at so many different features of companies in so many
ways that, even without the cocaine brain, he was missing obvious patterns.



His mental checklist wasn’t good enough. “I am not Warren,” he said. “I
don’t have a 300 IQ.” He needed an approach that could work for someone
with an ordinary IQ. So he devised a written checklist.

Apparently, Buffett himself could have used one. Pabrai noticed that even
he made certain repeated mistakes. “That’s when I knew he wasn’t really
using a checklist,” Pabrai said.

So Pabrai made a list of mistakes he’d seen—ones Buffett and other
investors had made as well as his own. It soon contained dozens of different
mistakes, he said. Then, to help him guard against them, he devised a
matching list of checks—about seventy in all. One, for example, came from
a Berkshire Hathaway mistake he’d studied involving the company’s
purchase in early 2000 of Cort Furniture, a Virginia-based rental furniture
business. Over the previous ten years, Cort’s business and profits had
climbed impressively. Charles Munger, Buffett’s longtime investment
partner, believed Cort was riding a fundamental shift in the American
economy. The business environment had become more and more volatile
and companies therefore needed to grow and shrink more rapidly than ever
before. As a result, they were increasingly apt to lease office space rather
than buy it—and, Munger noticed, to lease the furniture, too. Cort was in a
perfect position to benefit. Everything else about the company was
measuring up—it had solid financials, great management, and so on. So
Munger bought. But buying was an error. He had missed the

fact that the three previous years of earnings had been driven entirely by
the dot-com boom of the late nineties. Cort was leasing furniture to
hundreds of start-up companies that suddenly stopped paying their bills and
evaporated when the boom collapsed.

“Munger and Buffett saw the dot-com bubble a mile away,” Pabrai said.
“These guys were completely clear.” But they missed how dependent Cort
was on it. Munger later called his purchase “a macroeconomic mistake.”

“Cort’s earning power basically went from substantial to zero for a
while,” he confessed to his shareholders.

So Pabrai added the following checkpoint to his list: when analyzing a
company, stop and confirm that you’ve asked yourself whether the revenues
might be overstated or understated due to boom or bust conditions.

Like him, the anonymous investor I spoke to—I’ll call him Cook—made
a checklist. But he was even more methodical: he enumerated the errors



known to occur at any point in the investment process—during the research
phase, during decision making, during execution of the decision, and even
in the period after making an investment when one should be monitoring
for problems. He then designed detailed checklists to avoid the errors,
complete with clearly identified pause points at which he and his
investment team would run through the items.

He has a Day Three Checklist, for example, which he and his team
review at the end of the third day of considering an investment. By that
point, the checklist says, they should confirm that they have gone over the
prospect’s key financial statements for the previous ten years, including
checking for specific items in each statement and possible patterns across
the statements.

“It’s easy to hide in a statement. It’s hard to hide between statements,”
Cook said.

One check, for example, requires the members of the team to verify that
they’ve read the footnotes on the cash flow statements. Another has them
confirm they’ve reviewed the statement of key management risks. A third
asks them to make sure they’ve looked to see whether cash flow and costs
match the reported revenue growth.

“This is basic basic basic,” he said. “Just look! You’d be amazed by how
often people don’t do it.” Consider the Enron debacle, he said. “People
could have figured out it was a disaster entirely from the financial
statements.”

He told me about one investment he looked at that seemed a huge winner.
The cocaine brain was screaming. It turned out, however, that the
company’s senior officers, who’d been selling prospective investors on how
great their business was, had quietly sold every share they owned. The
company was about to tank and buyers jumping aboard had no idea. But
Cook had put a check on his three-day list that ensured his team had
reviewed the fine print of the company’s mandatory stock disclosures, and
he discovered the secret. Forty-nine times out of fifty, he said, there’s
nothing to be found. “But then there is.”

The checklist doesn’t tell him what to do, he explained. It is not a
formula. But the checklist helps him be as smart as possible every step of
the way, ensuring that he’s got the critical information he needs when he
needs it, that he’s systematic about decision making, that he’s talked to



everyone he should. With a good checklist in hand, he was convinced he
and his partners could make decisions as well as human beings are able.
And as a result, he was also convinced they could reliably beat the market.

I asked him whether he wasn’t fooling himself.
“Maybe,” he said. But he put it in surgical terms for me. “When surgeons

make sure to wash their hands or to talk to everyone on the team”—he’d
seen the surgery checklist—“they improve their outcomes with no increase
in skill. That’s what we are doing when we use the checklist.”

Cook would not discuss precise results—his fund does not disclose its
earnings publicly—but he said he had already seen the checklist deliver
better outcomes for him. He had put the checklist process in place at the
start of 2008 and, at a minimum, it appeared that he had been able to ride
out the subsequent economic collapse without disaster. Others say his fund
has done far better than that, outperforming its peers. How much of any
success can be directly credited to the checklist is not clear—after all, he’s
used it just two years so far. What Cook says is certain, however, was that
in a period of enormous volatility the checklist gave his team at least one
additional and unexpected edge over others: efficiency.

When he first introduced the checklist, he assumed it would slow his
team down, increasing the time and work required for their investment
decisions. He was prepared to pay that price. The benefits of making fewer
mistakes seemed obvious. And in fact, using the checklist did increase the
up-front work time. But to his surprise, he found they were able to evaluate
many more investments in far less time overall.

Before the checklist, Cook said, it sometimes took weeks and multiple
meetings to sort out how seriously they should consider a candidate
investment—whether they should drop it or pursue a more in-depth
investigation. The process was open-ended and haphazard, and when people
put a month into researching an investment, they tended to get, well,
invested. After the checklist, though, he and his team found that they could
consistently sort out by the three-day check which prospects really deserved
further consideration and which ones didn’t. “The process was more
thorough but faster,” he said. “It was one hit, and we could move on.”

Pabrai and Spier, the Zurich investor, found the same phenomenon. Spier
used to employ an investment analyst. But “I didn’t need him anymore,” he
said. Pabrai had been working with a checklist for about a year. His fund



was up more than 100 percent since then. This could not possibly be
attributed to just the checklist. With the checklist in place, however, he
observed that he could move through investment decisions far faster and
more methodically. As the markets plunged through late 2008 and
stockholders dumped shares in panic, there were numerous deals to be had.
And in a single quarter he was able to investigate more than a hundred
companies and add ten to his fund’s portfolios. Without the checklist,
Pabrai said, he could not have gotten through a fraction of the analytic work
or have had the confidence to rely on it. A year later, his investments were
up more than 160 percent on average. He’d made no mistakes at all.

What makes these investors’ experiences striking to me is not merely
their evidence that checklists might work as well in finance as they do in
medicine. It’s that here, too, they have found takers slow to come. In the
money business, everyone looks for an edge. If someone is doing well,
people pounce like starved hyenas to find out how. Almost every idea
formaking even slightly more money—investing in Internet companies,
buying tranches of sliced-up mortgages, whatever—gets sucked up by the
giant maw almost instantly. Every idea, that is, except one: checklists.

I asked Cook how much interest others have had in what he has been
doing these past two years. Zero, he said—or actually that’s not quite true.
People have been intensely interested in what he’s been buying and how,
but the minute the word checklist comes out of his mouth, they disappear.
Even in his own firm, he’s found it a hard sell.

“I got pushback from everyone. It took my guys months to finally see the
value,” he said. To this day, his partners still don’t all go along with his
approach and don’t use the checklist in their decisions when he’s not
involved.

“I find it amazing other investors have not even bothered to try,” he said.
“Some have asked. None have done it.”

The resistance is perhaps an inevitable response. Some years ago, Geoff
Smart, a Ph.D. psychologist who was then at Claremont Graduate
University, conducted a revealing research project. He studied fifty-one
venture capitalists, people who make gutsy, high-risk, multimillion-dollar
investments in unproven start-up companies. Their work is quite unlike that
of money managers like Pabrai and Cook and Spier, who invest in



established companies with track records and public financial statements
one can analyze. Venture capitalists bet on wild-eyed, greasy-haired,
underaged entrepreneurs pitching ideas that might be little more than
scribbles on a sheet of paper or a clunky prototype that barely works. But
that’s how Google and Apple started out, and the desperate belief of venture
capitalists is that they can find the next equivalent and own it.

Smart specifically studied how such people made their most difficult
decision in judging whether to give an entrepreneur money or not. You
would think that this would be whether the entrepreneur’s idea is actually a
good one. But finding a good idea is apparently not all that hard. Finding an
entrepreneur who can execute a good idea is a different matter entirely. One
needs a person who can take an idea from proposal to reality, work the long
hours, build a team, handle the pressures and setbacks, manage technical
and people problems alike, and stick with the effort for years on end
without getting distracted or going insane. Such people are rare and
extremely hard to spot.

Smart identified half a dozen different ways the venture capitalists he
studied decided whether they’d found such a person. These were styles of
thinking, really. He called one type of investor the “Art Critics.” They
assessed entrepreneurs almost at a glance, the way an art critic can assess
the quality of a painting—intuitively and based on long experience.
“Sponges” took more time gathering information about their targets,
soaking up whatever they could from interviews, on-site visits, references,
and the like. Then they went with whatever their guts told them. As one
such investor told Smart, he did “due diligence by mucking around.”

The “Prosecutors” interrogated entrepreneurs aggressively, testing them
with challenging questions about their knowledge and how they would
handle random hypothetical situations. “Suitors” focused more on wooing
people than on evaluating them. “Terminators” saw the whole effort as
doomed to failure and skipped the evaluation part. They simply bought
what they thought were the best ideas, fired entrepreneurs they found to be
incompetent, and hired replacements.

Then there were the investors Smart called the “Airline Captains.” They
took a methodical, checklist-driven approach to their task. Studying past
mistakes and lessons from others in the field, they built formal checks into
their process. They forced themselves to be disciplined and not to skip



steps, even when they found someone they “knew” intuitively was a real
prospect.

Smart next tracked the venture capitalists’ success over time. There was
no question which style was most effective—and by now you should be
able to guess which one. It was the Airline Captain, hands down. Those
taking the checklist-driven approach had a 10 percent likelihood of later
having to fire senior management for incompetence or concluding that their
original evaluation was inaccurate. The others had at least a 50 percent
likelihood.

The results showed up in their bottom lines, too. The Airline Captains
had a median 80 percent return on the investments studied, the others 35
percent or less. Those with other styles were not failures by any stretch—
experience does count for something. But those who added checklists to
their experience proved substantially more successful.

The most interesting discovery was that, despite the disadvantages, most
investors were either Art Critics or Sponges—intuitive decision makers
instead of systematic analysts. Only one in eight took the Airline Captain
approach. Now, maybe the others didn’t know about the Airline Captain
approach. But even knowing seems to make little difference. Smart
published his findings more than a decade ago. He has since gone on to
explain them in a best-selling business book on hiring called Who. But
when I asked him, now that the knowledge is out, whether the proportion of
major investors taking the more orderly, checklist-driven approach has
increased substantially, he could only report, “No. It’s the same.”

We don’t like checklists. They can be painstaking. They’re not much fun.
But I don’t think the issue here is mere laziness. There’s something deeper,
more visceral going on when people walk away not only from saving lives
but from making money. It somehow feels beneath us to use a checklist, an
embarrassment. It runs counter to deeply held beliefs about how the truly
great among us—those we aspire to be—handle situations of high stakes
and complexity. The truly great are daring. They improvise. They do not
have protocols and checklists.

Maybe our idea of heroism needs updating.

On January 14, 2009, WHO’s safe surgery checklist was made public. As
it happened, the very next day, US Airways Flight 1549 took off from La



Guardia Airport in New York City with 155 people on board, struck a large
flock of Canadian geese over Manhattan, lost both engines, and famously
crash-landed in the icy Hudson River. The fact that not a single life was lost
led the press to christen the incident the “miracle on the Hudson.” A
National Transportation Safety Board official said the flight “has to go
down as the most successful ditching in aviation history.” Fifty-seven-year-
old Captain Chesley B. “Sully” Sullenberger III, a former air force pilot
with twenty thousand hours of flight experience, was hailed the world over.

“Quiet Air Hero Is Captain America,” shouted the New York Post
headline. ABC News called him the “Hudson River hero.” The German
papers hailed “Der Held von New York,” the French “Le Nouveau Héros de
l’Amérique,” the Spanish-language press “El Héroe de Nueva York.”
President George W. Bush phoned Sullenberger to thank him personally,
and President-elect Barack Obama invited him and his family to attend his
inauguration five days later. Photographers tore up the lawn of his Danville,
California, home trying to get a glimpse of his wife and teenage children.
He was greeted with a hometown parade and a $3 million book deal.

But as the details trickled out about the procedures and checklists that
were involved, the fly-by-wire computer system that helped control the
glide down to the water, the copilot who shared flight responsibilities, the
cabin crew who handled the remarkably swift evacuation, we the public
started to become uncertain about exactly who the hero here was. As
Sullenberger kept saying over and over from the first of his interviews
afterward, “I want to correct the record right now. This was a crew effort.”
The outcome, he said, was the result of teamwork and adherence to
procedure asmuch as of any individual skill he may have had.

Aw, that’s just the modesty of the quiet hero, we finally insisted. The next
month, when the whole crew of five—not just Sullenberger—was brought
out to receive the keys to New York City, for “exclusive” interviews on
every network, and for a standing ovation by an audience of seventy
thousand at the Super Bowl in Tampa Bay, you could see the press had
already determined how to play this. They didn’t want to talk about
teamwork and procedure. They wanted to talk about Sully using his
experience flying gliders as an Air Force Academy cadet.

“That was so long ago,” Sullenberger said, “and those gliders are so
different from a modern jet airliner. I think the transfer of experience was



not large.”
It was as if we simply could not process the full reality of what had been

required to save the people on that plane.

The aircraft was a European-built Airbus A320 with two jet engines, one
on each wing. The plane took off at 3:25 p.m. on a cold but clear afternoon,
headed for Charlotte, North Carolina, with First Officer Jeffrey Skiles at the
controls and Sullenberger serving as the pilot not flying. The first thing to
note is that the two had never flown together before that trip. Both were
tremendously experienced. Skiles had nearly as many flight hours as
Sullenberger and had been a longtime Boeing 737 captain until downsizing
had forced him into the right-hand seat and retraining to fly A320s. This
much experience may sound like a good thing, but it isn’t necessarily.
Imagine two experienced but unacquainted lawyers meeting to handle your
case on your opening day in court. Or imagine two top basketball coaches
who are complete strangers stepping onto the parquet to lead a team in a
championship game. Things could go fine, but it is more likely that they
will go badly.

Before the pilots started the plane’s engines at the gate, however, they
adhered to a strict discipline—the kind most other professions avoid. They
ran through their checklists. They made sure they’d introduced themselves
to each other and the cabin crew. They did a short briefing, discussing the
plan for the flight, potential concerns, and how they’d handle troubles if
they ran into them. And by adhering to this discipline—by taking just those
few short minutes—they not only made sure the plane was fit to travel but
also transformed themselves from individuals into a team, one
systematically prepared to handle whatever came their way.

I don’t think we recognize how easy it would have been for Sullenberger
and Skiles to have blown off those preparations, to have cut corners that
day. The crew had more than 150 total years of flight experience—150
years of running their checklists over and over and over, practicing them in
simulators, studying the annual updates. The routine can seem pointless
most of the time. Not once had any of them been in an airplane accident.
They fully expected to complete their careers without experiencing one,
either. They considered the odds of anything going wrong extremely low,



far lower than we do in medicine or investment or legal practice or other
fields. But they ran through their checks anyway.

It need not have been this way. As recently as the 1970s, some airline
pilots remained notoriously bluff about their preparations, however
carefully designed. “I’ve never had a problem,” they would say. Or “Let’s
get going. Everything’s fine.” Or “I’m the captain. This is my ship. And
you’re wasting my time.” Consider, for example, the infamous 1977
Tenerife disaster. It was the deadliest accident in aviation history. Two
Boeing 747 airliners collided at high speed in fog on a Canary Islands
runway, killing 583 people on board. The captain on one of the planes, a
KLM flight, had misunderstood air traffic control instructions conveying
that he was not cleared for takeoff on the runway—and disregarded the
second officer, who recognized that the instructions were unclear. There
was in fact a Pan American flight taking off in the opposite direction on the
same runway.

“Is he not cleared, that Pan American?” the second officer said to the
captain.

“Oh yes,” the captain insisted, and continued onto the runway.
The captain was wrong. The second officer sensed it. But they were not

prepared for this moment. They had not taken the steps to make themselves
a team. As a result, the second officer never believed he had the permission,
let alone the duty, to halt the captain and clear up the confusion. Instead the
captain was allowed to plow ahead and kill them all.

The fear people have about the idea of adherence to protocol is rigidity.
They imagine mindless automatons, heads down in a checklist, incapable of
looking out their windshield and coping with the real world in front of
them. But what you find, when a checklist is well made, is exactly the
opposite. The checklist gets the dumb stuff out of the way, the routines your
brain shouldn’t have to occupy itself with (Are the elevator controls set?
Did the patient get her antibiotics on time? Did the managers sell all their
shares? Is everyone on the same page here?), and lets it rise above to focus
on the hard stuff (Where should we land?).

Here are the details of one of the sharpest checklists I’ve seen, a checklist
for engine failure during flight in a single-engine Cessna airplane—the US
Airways situation, only with a solo pilot. It is slimmed down to six key
steps not to miss for restarting the engine, steps like making sure the fuel



shutoff valve is in the OPEN position and putting the backup fuel pump
switch ON. But step one on the list is the most fascinating. It is simply:
FLY THE AIRPLANE. Because pilots sometimes become so desperate
trying to restart their engine, so crushed by the cognitive overload of
thinking through what could have gone wrong, they forget this most basic
task. FLY THE AIRPLANE. This isn’t rigidity. This is making sure
everyone has their best shot at survival.

About ninety seconds after takeoff, US Airways Flight 1549 was climbing
up through three thousand feet when it crossed the path of the geese. The
plane came upon the geese so suddenly Sullenberger’s immediate reaction
was to duck. The sound of the birds hitting the windshield and the engines
was loud enough to be heard on the cockpit voice recorder. As news reports
later pointed out, planes have hit hundreds of thousands of birds without
incident. But dual bird strikes are rare. And, in any case, jet engines are
made to handle most birds, more or less liquefying them. Canadian geese,
however, are larger than most birds, often ten pounds and up, and no engine
can handle them. Jet engines are designed instead to shut down after
ingesting one, without exploding or sending metal shrapnel into the wings
or the passengers on board. That’s precisely what the A320’s engines did
when they were hit with the rarest of rare situations—at least three geese in
the two engines. They immediately lost power.

Once that happened, Sullenberger made two key decisions: first, to take
over flying the airplane from his copilot, Skiles, and, second, to land in the
Hudson. Both seemed clear choices at the time and were made almost
instinctively. Within a minute it became apparent that the plane had too
little speed to make it to La Guardia or to the runway in Teterboro, New
Jersey, offered by air traffic control. As for taking over the piloting, both he
and Skiles had decades of flight experience, but Sullenberger had logged far
more hours flying the A320. All the key landmarks to avoid hitting—
Manhattan’s skyscrapers, the George Washington Bridge—were out his left-
side window. And Skiles had also just completed A320 emergency training
and was more recently familiar with the checklists they would need.

“My aircraft,” Sullenberger said, using the standard language as he put
his hands on the controls.



“Your aircraft,” Skiles replied. There was no argument about what to do
next, not even a discussion. And there was no need for one. The pilots’
preparations had made them a team. Sullenberger would look for the
nearest, safest possible landing site. Skiles would go to the engine failure
checklists and see if he could relight the engines. But for the computerized
voice of the ground proximity warning system saying “Pull up. Pull up. Pull
up. Pull up,” the cockpit was virtually silent as each pilot concentrated on
his tasks and observed the other for cues that kept them coordinated.

Both men played crucial roles here. We treat copilots as if they are
superfluous—backups who are given a few tasks so that they have
something to do. But given the complexity of modern airplanes, they are as
integral to a successful flight as anesthesiologists are to a successful
operation. Pilot and copilot alternate taking the flight controls and
managing the flight equipment and checklist responsibilities, and when
things go wrong it’s not at all clear which is the harder job. The plane had
only three and a half minutes of glide in it. In that time, Skiles needed to
make sure he’d done everything possible to relight the engines while also
preparing the aircraft for ditching if it wasn’t feasible. But the steps
required just to restart one engine typically take more time than that. He had
some choices to make.

Plunging out of the sky, he judged that their best chance at survival would
come from getting an engine restarted. So he decided to focus almost
entirely on the engine failure checklist and running through it as fast as he
could. The extent of damage to the engines was unknown, but regaining
even partial power would have been sufficient to get the plane to an airport.
In the end, Skiles managed to complete a restart attempt on both engines,
something investigators later testified to be “very remarkable” in the time
frame he had—and something they found difficult to replicate in
simulation.

Yet he did not ignore the ditching procedure, either. He did not have time
to do everything on the checklist. But he got the distress signals sent, and he
made sure the plane was properly configured for an emergency water
landing.

“Flaps out?” asked Sullenberger.
“Got flaps out,” responded Skiles.



Sullenberger focused on the glide down to the water. But even in this, he
was not on his own. For, as journalist and pilot William Langewiesche
noted afterward, the plane’s fly-by-wire control system was designed to
assist pilots in accomplishing a perfect glide without demanding unusual
skills. It eliminated drift and wobble. It automatically coordinated the
rudder with the roll of the wings. It gave Sullenberger a green dot on his
screen to target for optimal descent. And it maintained the ideal angle to
achieve lift, while preventing the plane from accidentally reaching “radical
angles” during flight that would have caused it to lose its gliding ability.
The system freed him to focus on other critical tasks, like finding a landing
site near ferries in order to give passengers their best chance of rescue and
keeping the wings level as the plane hit the water’s surface.

Meanwhile, the three flight attendants in the cabin—Sheila Dail, Donna
Dent, and Doreen Welsh—followed through on their protocols for such
situations. They had the passengers put their heads down and grab their legs
to brace for impact. Upon landing and seeing water through the windows,
the flight attendants gave instructions to don life vests. They made sure the
doors got open swiftly when the plane came to a halt, that passengers didn’t
waste time grabbing for their belongings, or trap themselves by inflating
life vests inside the aircraft. Welsh, stationed in the very back, had to wade
through ice cold, chest-high water leaking in through the torn fuselage to do
her part. Just two of the four exits were safely accessible. Nonetheless,
working together they got everyone out of a potentially sinking plane in just
three minutes—exactly as designed.

While the evacuation got under way, Sullenberger headed back to check
on the passengers and the condition of the plane. Meanwhile, Skiles
remained up in the cockpit to run the evacuation checklist—making sure
potential fire hazards were dealt with, for instance. Only when it was
completed did he emerge. The arriving flotilla of ferries and boats proved
more than sufficient to get everyone out of the water. Air in the fuel tanks,
which were only partly full, kept the plane stable and afloat. Sullenberger
had time for one last check of the plane. He walked the aisle to make sure
no one had been forgotten, and then he exited himself.

The entire event had gone shockingly smoothly. After the plane landed,
Sullenberger said, “First Officer Jeff Skiles and I turned to each other and,



almost in unison, at the same time, with the same words, said to each other,
‘Well, that wasn’t as bad as I thought.’ ”

So who was the hero here? No question, there was something miraculous
about this flight. Luck played a huge role. The incident occurred in
daylight, allowing the pilots to spot a safe landing site. Plenty of boats were
nearby for quick rescue before hypothermia set in. The bird strike was
sufficiently high to let the plane clear the George Washington Bridge. The
plane was also headed downstream, with the current, instead of upstream or
over the ocean, limiting damage on landing.

Nonetheless, even with fortune on their side, there remained every
possibility that 155 lives could have been lost that day. But what rescued
them was something more exceptional, difficult, crucial, and, yes, heroic
than flight ability. The crew of US Airways Flight 1549 showed an ability
to adhere to vital procedures when it mattered most, to remain calm under
pressure, to recognize where one needed to improvise and where one
needed not to improvise. They understood how to function in a complex
and dire situation. They recognized that it required teamwork and
preparation and that it required them long before the situation became
complex and dire.

This was what was unusual. This is what it means to be a hero in the
modern era. These are the rare qualities that we must understand are needed
in the larger world.

All learned occupations have a definition of professionalism, a code of
conduct. It is where they spell out their ideals and duties. The codes are
sometimes stated, sometimes just understood. But they all have at least
three common elements.

First is an expectation of selflessness: that we who accept responsibility
for others—whether we are doctors, lawyers, teachers, public authorities,
soldiers, or pilots—will place the needs and concerns of those who depend
on us above our own. Second is an expectation of skill: that we will aim for
excellence in our knowledge and expertise. Third is an expectation of
trustworthiness: that we will be responsible in our personal behavior toward
our charges.

Aviators, however, add a fourth expectation, discipline: discipline in
following prudent procedure and in functioning with others. This is a



concept almost entirely outside the lexicon of most professions, including
my own. In medicine, we hold up “autonomy” as a professional lodestar, a
principle that stands in direct opposition to discipline. But in a world in
which success now requires large enterprises, teams of clinicians, high-risk
technologies, and knowledge that outstrips any one person’s abilities,
individual autonomy hardly seems the ideal we should aim for. It has the
ring more of protectionism than of excellence. The closest our professional
codes come to articulating the goal is an occasional plea for “collegiality.”
What is needed, however, isn’t just that people working together be nice to
each other. It is discipline.

Discipline is hard—harder than trustworthiness and skill and perhaps
even than selflessness. We are by nature flawed and inconstant creatures.
We can’t even keep from snacking between meals. We are not built for
discipline. We are built for novelty and excitement, not for careful attention
to detail. Discipline is something we have to work at.

That’s perhaps why aviation has required institutions to make discipline a
norm. The preflight checklist began as an invention of a handful of army
pilots in the 1930s, but the power of their discovery gave birth to entire
organizations. In the United States, we now have the National
Transportation Safety Board to study accidents—to independently
determine the underlying causes and recommend how to remedy them. And
we have national regulations to ensure that those recommendations are
incorporated into usable checklists and reliably adopted in ways that
actually reduce harm.

To be sure, checklists must not become ossified mandates that hinder
rather than help. Even the simplest requires frequent revisitation and
ongoing refinement. Airline manufacturers put a publication date on all
their checklists, and there is a reason why—they are expected to change
with time. In the end, a checklist is only an aid. If it doesn’t aid, it’s not
right. But if it does, we must be ready to embrace the possibility.

We have most readily turned to the computer as our aid. Computers hold
out the prospect of automation as our bulwark against failure. Indeed, they
can take huge numbers of tasks off our hands, and thankfully already have
—tasks of calculation, processing, storage, transmission. Without question,
technology can increase our capabilities. But there is much that technology
cannot do: deal with the unpredictable, manage uncertainty, construct a



soaring building, perform a lifesaving operation. In many ways, technology
has complicated these matters. It has added yet another element of
complexity to the systems we depend on and given us entirely new kinds of
failure to contend with.

One essential characteristic of modern life is that we all depend on
systems—on assemblages of people or technologies or both—and among
our most profound difficulties is making them work. In medicine, for
instance, if I want my patients to receive the best care possible, not only
must I do a good job but a whole collection of diverse components have to
somehow mesh together effectively. Health care is like a car that way,
points out Donald Berwick, president of the Institute for Healthcare
Improvement in Boston and one of our deepest thinkers about systems in
medicine. In both cases, having great components is not enough.

We’re obsessed in medicine with having great components— the best
drugs, the best devices, the best specialists—but pay little attention to how
to make them fit together well. Berwick notes how wrongheaded this
approach is. “Anyone who understands systems will know immediately that
optimizing parts is not a good route to system excellence,” he says. He
gives the example of a famous thought experiment of trying to build the
world’s greatest car by assembling the world’s greatest car parts. We
connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a
BMW, the body of a Volvo. “What we get, of course, is nothing close to a
great car; we get a pile of very expensive junk.”

Nonetheless, in medicine that’s exactly what we have done. We have a
thirty-billion-dollar-a-year National Institutes of Health, which has been a
remarkable powerhouse of medical discoveries. But we have no National
Institute of Health Systems Innovation alongside it studying how best to
incorporate these discoveries into daily practice—no NTSB equivalent
swooping in to study failures the way crash investigators do, no Boeing
mapping out the checklists, no agency tracking the month-to-month results.

The same can be said in numerous other fields. We don’t study routine
failures in teaching, in law, in government programs, in the financial
industry, or elsewhere. We don’t look for the patterns of our recurrent
mistakes or devise and refine potential solutions for them.

But we could, and that is the ultimate point. We are all plagued by
failures—bymissed subtleties, overlooked knowledge, and outright errors.



For the most part, we have imagined that little can be done beyond working
harder and harder to catch the problems and clean up after them. We are not
in the habit of thinking the way the army pilots did as they looked upon
their shiny new Model 299 bomber—a machine so complex no one was
sure human beings could fly it. They too could have decided just to “try
harder” or to dismiss a crash as the failings of a “weak” pilot.

Instead they chose to accept their fallibilities. They recognized the
simplicity and power of using a checklist.

And so can we. Indeed, against the complexity of the world, we must.
There is no other choice. When we look closely, we recognize the same
balls being dropped over and over, even by those of great ability and
determination. We know the patterns. We see the costs. It’s time to try
something else.

Try a checklist.



9. THE SAVE

In the spring of 2007, as soon as our surgery checklist began taking
form, I began using it in my own operations. I did so not because I thought
it was needed but because I wanted to make sure it was really usable. Also,
I did not want to be a hypocrite. We were about to trot this thing out in eight
cities around the world. I had better be using it myself. But in my heart of
hearts—if you strapped me down and threatened to take out my appendix
without anesthesia unless I told the truth—did I think the checklist would
make much of a difference in my cases? No. In my cases? Please.

To my chagrin, however, I have yet to get through a week in surgery
without the checklist’s leading us to catch something we would have
missed. Take last week, as I write this, for instance. We had three catches in
five cases.

I had a patient who hadn’t gotten the antibiotic she should have received
before the incision, which is one of our most common catches. The
anesthesia team had gotten distracted by the usual vicissitudes. They had
trouble finding a good vein for an IV, and one of the monitors was being
twitchy. Then the nurse called a time-out for the team to run the Before
Incision check.

“Has the antibiotic been given within the last sixty minutes?” I asked,
reading my lines off a wall poster.

“Oh, right, um, yes, it will be,” the anesthesia resident replied. We waited
a quiet minute for the medication to flow in before the scrub tech handed
over the knife.

I had another patient who specifically didn’t want the antibiotic.
Antibiotics give her intestinal upset and yeast infections, she said. She
understood the benefits, but the risk of a bacterial wound infection in her
particular operation was low—about 1 percent— and she was willing to
take her chances. Yet giving an antibiotic was so automatic (when we
weren’t distracted from it) that we twice nearly infused it into her, despite



her objections. The first time was before she went to sleep and she caught
the error herself. The second time was after and the checklist caught it. As
we went around the room at the pause before the incision, making sure no
one had any concerns, the nurse reminded everyone not to give the
antibiotic. The anesthesia attending reacted with surprise. She hadn’t been
there for the earlier conversation and was about to drip it in.

The third catch involved a woman in her sixties for whom I was doing a
neck operation to remove half of her thyroid because of potential cancer.
She’d had her share of medical problems and required a purseful of
medications to keep them under control. She’d also been a longtime heavy
smoker but had quit a few years before. There seemed to be no significant
lingering effects. She could climb two flights of stairs without shortness of
breath or chest pain. She looked generallywell. Her lungs sounded clear and
without wheezes under my stethoscope. The records showed no pulmonary
diagnoses. But when she met the anesthesiologist before surgery, she
remembered that she’d had trouble breathing after two previous operations
and had required oxygen at home for several weeks. In one instance, she’d
required a stay in intensive care.

This was a serious concern. The anesthesiologist knew about it, but I
didn’t—not until we ran the checklist. When the moment came to raise
concerns, the anesthesiologist asked why I wasn’t planning to watch her
longer than the usual few hours after day surgery, given her previous
respiratory problems.

“What respiratory problems?” I said. The full story came out from there.
We made arrangements to keep the patient in the hospital for observation.
Moreover, we made plans to give her inhalers during surgery and afterward
to prevent breathing problems. They worked beautifully. She never needed
extra oxygen at all.

No matter how routine an operation is, the patients never seem to be. But
with the checklist in place, we have caught unrecognized drug allergies,
equipment problems, confusion about medications, mistakes on labels for
biopsy specimens going to pathology. (“No, that one is from the right side.
This is the one from the left side.”)We’ve made better plans and been better
prepared for patients. I am not sure how many important issues would have
slipped by us without the checklist and actually caused harm. We were not
bereft of defenses. Our usual effort to be vigilant and attentive might have



caught some of the problems. And those we didn’t catch may never have
gone on to hurt anyone.

I had one case, however, in which I know for sure the checklist saved my
patient’s life. Mr. Hagerman, as we’ll call him, was a fifty-three-year-old
father of two and the CEO of a local company, and I had brought him to the
operating room to remove his right adrenal gland because of an unusual
tumor growing inside it called a pheochromocytoma. Tumors like his pour
out dangerous levels of adrenalin and can be difficult to remove. They are
also exceedingly rare. But in recent years, I’ve developed alongside my
general surgery practice a particular interest and expertise in endocrine
surgery. I’ve now removed somewhere around forty adrenal tumors without
complication. So when Mr. Hager-man came to see me about this strange
mass in his right adrenal gland, I felt quite confident about my ability to
help him. There is always a risk of serious complications, I explained—the
primary danger occurs when you’re taking the gland off the vena cava, the
main vessel returning blood to the heart, because injuring the vena cava can
cause life-threatening bleeding. But the likelihood was low, I reassured him.

Once you’re in the operating room, however, you either have a
complication or you don’t. And with him I did.

I was doing the operation laparoscopically, freeing the tumor with
instruments I observed on a video monitor using a fiberoptic camera we put
inside Mr. Hagerman. All was going smoothly. I was able to lift the liver up
and out of the way, and underneath I found the soft, tan yellow mass, like
the yolk of a hard-boiled egg. I began dissecting it free of the vena cava,
and although doing so was painstaking, it didn’t seem unusually difficult.
I’d gotten the tumor mostly separated when I did something I’d never done
before: I made a tear in the vena cava.

This is a catastrophe. I might as well have made a hole directly in Mr.
Hagerman’s heart. The bleeding that resulted was terrifying. He lost almost
his entire volume of blood into his abdomen in about sixty seconds and
went into cardiac arrest. I made a huge slashing incision to open his chest
and belly as fast and wide as I could. I took his heart in my hand and began
compressing it— one-two-three-squeeze, one-two-three-squeeze—to keep
his blood flow going to his brain. The resident assisting me held pressure on
the vena cava to slow the torrent. But in the grip of my fingers, I could feel
the heart emptying out.



I thought it was over, that we’d never get Mr. Hagerman out of the
operating room alive, that I had killed him. But we had run the checklist at
the start of the case. When we had come to the part where I was supposed to
discuss how much blood loss the team should be prepared for, I said, “I
don’t expect much blood loss. I’ve never lost more than one hundred cc’s.”
I was confident. I was looking forward to this operation. But I added that
the tumor was pressed right up against the vena cava and that significant
blood loss remained at least a theoretical concern. The nurse took that as a
cue to check that four units of packed red cells had been set aside in the
blood bank, like they were supposed to be—“just in case,” as she said.

They hadn’t been, it turned out. So the blood bank got the four units
ready. And as a result, from this one step alone, the checklist saved my
patient’s life.

Just as powerful, though, was the effect that the routine of the checklist—
the discipline—had on us. Of all the people in the room as we started that
operation—the anesthesiologist, the nurse anesthetist, the surgery resident,
the scrub nurse, the circulating nurse, the medical student—I had worked
with only two before, and I knew only the resident well. But as we went
around the room introducing ourselves—“Atul Gawande, surgeon.” “Rich
Bafford, surgery resident.” “Sue Marchand, nurse”—you could feel the
room snapping to attention. We confirmed the patient’s name on his ID
bracelet and that we all agreed which adrenal gland was supposed to come
out. The anesthesiologist confirmed that he had no critical issues to mention
before starting, and so did the nurses. We made sure that the antibiotics
were in the patient, a warming blanket was on his body, the inflating boots
were on his legs to keep blood clots from developing. We came into the
room as strangers. But when the knife hit the skin, we were a team.

As a result, when I made the tear and put disaster upon us, everyone kept
their head. The circulating nurse called an alarm for extra personnel and got
the blood from the blood bank almost instantly. The anesthesiologist began
pouring unit after unit into the patient. Forces were marshaled to bring in
the additional equipment I requested, to page the vascular surgeon I wanted,
to assist the anesthesiologist with obtaining more intravenous access, to
keep the blood bank apprised. And together the team got me—and the
patient—precious time. They ended up transfusing more than thirty units of
blood into him—he lost three times as much blood as his body contained to



begin with. And with our eyes on the monitor tracing his blood pressure and
my hand squeezing his heart, it proved enough to keep his circulation
going. The vascular surgeon and I had time to work out an effective way to
clamp off the vena cava tear. I could feel his heart begin beating on its own
again. We were able to put in sutures and close the hole. And Mr. Hagerman
survived.

I cannot pretend he escaped unscathed. The extended period of low blood
pressure damaged an optic nerve and left him essentially blind in one eye.
He didn’t get off the respirator for days. He was out of work for months. I
was crushed by what I had put him through. Though I apologized to him
and carried on with my daily routine, it took me a long time to feel right
again in surgery. I can’t do an adrenalectomy without thinking of his case,
and I suspect that is good. I have even tried refining the operative technique
in hopes of coming up with better ways to protect the vena cava and keep
anything like his experience from happening again.

But more than this, because of Mr. Hagerman’s operation, I have come to
be grateful for what a checklist can do. I do not like to think how much
worse the case could have been. I do not like to think about having to walk
out to that family waiting area and explain to his wife that her husband had
died.

I spoke to Mr. Hagerman not long ago. He had sold his company with
great success and was in the process of turning another company around.
He was running three days a week. He was even driving.

“I have to watch out for my blind spot, but I can manage,” he said.
He had no bitterness, no anger, and this is remarkable to me. “I count

myself lucky just to be alive,” he insisted. I asked him if I could have
permission to tell others his story.

“Yes,” he said. “I’d be glad if you did.”



NOTES ON SOURCES

INTRODUCTION
7 “In the 1970s”: S. Gorovitz and A. MacIntyre, “Toward a Theory of

Medical Fallibility,” Journal of Medicine and Philosophy 1 (1976): 51–
71.

9 “The first safe medication”: M. Hamilton and E. N. Thompson, “The
Role of Blood Pressure Control in Preventing Complications of
Hypertension,” Lancet 1 (1964): 235–39. See also VA Cooperative
Study Group, “Effects of Treatment on Morbidity of Hypertension,”
Journal of the American Medical Association 202 (1967): 1028–33.

10 “After that, survival”: R. L. McNamara et al., “Effect of Door-to-
Balloon Time on Mortality in Patients with ST-Segment Elevation
Myocardial Infarction,” Journal of the American College of Cardiology
47 (2006): 2180–86.

10 “In 2006”: E. H. Bradley et al., “Strategies for Reducing the Door-to-
Balloon Time in Acute Myocardial Infarction,” New England Journal
of Medicine 355 (2006): 2308–20.

10 “Studies have found”: E. A. McGlynn et al., “Rand Research Brief:
The First National Report Card on Quality of Health Care in America,”
Rand Corporation, 2006.

11 “You see it in the 36 percent increase”: American Bar Association,
Profile of Legal Malpractice Claims, 2004–2007 (Chicago: American
Bar Association, 2008).

1. THE PROBLEM OF EXTREME COMPLEXITY
15 “I read a case report”:M. Thalmann, N. Trampitsch, M. Haberfellner,

et al., “Resuscitation in Near Drowning with Extracorporeal Membrane
Oxygenation,” Annals of Thoracic Surgery 72 (2001): 607–8.



21 “The answer that came back”: Further details of the analysis by
Marcus Semel, Richard Marshall, and Amy Marston will appear in a
forthcoming scientific article.

23 “On any given day”: Society of Critical Care Medicine, Critical Care
Statistics in the United States, 2006.

23 “The average stay”: J. E. Zimmerman et al., “Intensive Care Unit
Length of Stay: Benchmarking Based on Acute Physiology and
Chronic Health Evaluation (APACHE) IV,” Critical Care Medicine 34
(2006): 2517–29.

23 “Fifteen years ago”: Y. Donchin et al., “A Look into the Nature and
Causes of Human Errors in the Intensive Care Unit,” Critical Care
Medicine 23 (1995): 294–300.

24 “There are dangers simply”: N. Vaecker et al., “Bone Resorption Is
Induced on the Second Day of Bed Rest: Results of a Controlled,
Crossover Trial,” Journal of Applied Physiology 95 (2003): 977–82.

28 “national statistics show”: Centers for Disease Control, “National
Nosocomial Infection Surveillance (NNIS) System Report, 2004, Data
Summary from January 1992 through June 2004, Issued October
2004,” American Journal of Infection Control 32 (2004): 470–85.

28 “Those who survive line infections”: P. Kalfon et al., “Comparison of
Silver-Impregnated with Standard Multi-Lumen Central Venous
Catheters in Critically Ill Patients,” Critical Care Medicine 35 (2007):
1032–39.

28 “All in all, about half ”: S. Ghorra et al., “Analysis of the Effect of
Conversion from Open to Closed Surgical Intensive Care Units,”
Annals of Surgery 2 (1999): 163–71.

2. THE CHECKLIST
32 “On October 30, 1935”: P. S. Meilinger, “When the Fortress Went

Down,” Air Force Magazine, Oct. 2004, pp. 78–82.
35 “A study of forty-one thousand”: J. R. Clarke, A. V. Ragone, and L.

Greenwald, “Comparisons of Survival Predictions Using Survival Risk
Ratios Based on International Classification of Diseases, Ninth
Revision and Abbreviated Injury Scale Trauma Diagnosis Codes,”
Journal of Trauma 59 (2005): 563–69.



35 “Practitioners have had the means”: J. V. Stewart, Vital Signs and
Resuscitation (Georgetown, TX: Landes Bioscience, 2003).

38 “In more than a third of patients”: S. M. Berenholtz et al.,
“Eliminating Catheter-Related Bloodstream Infections in the Intensive
Care Unit,” Critical Care Medicine 32 (2004): 2014–20.

39 “This reduced from 41 percent”: M. A. Erdek and P. J. Pronovost,
“Improvement of Assessment and Treatment of Pain in the Critically
Ill,” International Journal for Quality Improvement in Healthcare 16
(2004): 59–64.

39 “The proportion of patients”: S. M. Berenholtz et al., “Improving Care
for the Ventilated Patient,” Joint Commission Journal on Quality and
Safety 4 (2004): 195–204.

39 “The researchers found”: P. J. Pronovost et al., “Improving
Communication in the ICU Using Daily Goals,” Journal of Critical
Care 18 (2003): 71–75.

39 “In a survey of ICU staff ”: Berenholtz et al., “Improving Care.”
41 “But between 2000 and 2003”: K. Norris, “DMC Ends 2004 in the

Black, but Storm Clouds Linger,” Detroit Free Press, March 30, 2005.
44 “In December 2006”: P. J. Pronovost et al., “An Intervention to

Reduce Catheter-Related Bloodstream Infections in the ICU,” New
England Journal of Medicine 355 (2006): 2725–32.

3. THE END OF THE MASTER BUILDER
48 “Two professors who study”: S. Glouberman and B. Zimmerman,

“Complicated and Complex Systems: What Would Successful Reform
of Medicare Look Like?” discussion paper no. 8, Commission on the
Future of Health Care in Canada, Saskatoon, 2002.

54 “His firm, McNamara/Salvia”: Portfolio at www.mcsal.com.
59 “We’ve been slow to adapt”: Data from the Dartmouth Atlas of Health

Care, www.darmouthatlas.org.
69 “It was planned to rise”: R. J. McNamara, “Robert J. McNamara, SE,

FASCE,” Structural Design of Tall and Special Buildings 17 (2008):
493–512.

70 “But, as a New Yorker story”: Joe Morgenstern, “The Fifty-Nine-Story
Crisis,” New Yorker, May 29, 1995.



71 “In the United States”: U.S. Census data for 2003 and 2008, www
.census.gov; K. Wardhana and F. C. Hadipriono, “Study of Recent
Building Failures in the United States,” Journal of Performance of
Constructed Facilities 17 (2003): 151–58.

4. THE IDEA
73 “At 6:00 a.m.”: Hurricane Katrina events and data from E. Scott,

“Hurricane Katrina,” Managing Crises: Responses to Large-Scale
Emergencies, ed. A. M. Howitt and H. B. Leonard (Washington, D.C.:
CQ Press, 2009), pp. 13–74.

76 “Of all organizations”: Wal-Mart events and data from S. Rose-grant,
“Wal-Mart’s Response to Hurricane Katrina,” Managing Crises, pp.
379–406.

78 “For every Wal-Mart”: D. Gross, “What FEMA Could Learn from
Wal-Mart: Less Than You Think,” Slate, Sept. 23, 2005, http://
www.slate.com/id/2126832.

78 “In the early days”: Scott, “Hurricane Katrina,” p. 49.
80 “As Roth explained”: D. L. Roth, Crazy from the Heat (New York:

Hyperion, 1997).
81 “Her focus is on regional Italian cuisine”: J. Adams and K. Rivard, In

the Hands of a Chef: Cooking with Jody Adams of Rialto Restaurant
(New York:William Morrow, 2002).

5. THE FIRST TRY
87 “By 2004”: T. G. Weiser et al., “An Estimation of the Global Volume

of Surgery: A Modelling Strategy Based on Available Data,” Lancet
372 (2008): 139–44.

87 “Although most of the time”: A. A. Gawande et al., “The Incidence
and Nature of Surgical Adverse Events in Colorado and Utah in 1992,”
Surgery 126 (1999): 66–75.

87 “Worldwide, at least seven million people”: Weiser, “An Estimation,”
and World Health Organization, World Health Report, 2004 (Geneva:
WHO, 2004). See annex, table 2.



91 “The strategy has shown results”: P. K. Lindenauer et al., “Public
Reporting and Pay for Performance in Hospital Quality Improvement,”
New England Journal of Medicine 356 (2007): 486–96.

93 “When the disease struck”: S. Johnson, The Ghost Map (New York:
Riverhead, 2006).

95 “Luby and his team reported”: S. P. Luby et al., “Effect of Hand-
washing on Child Health: A Randomised Controlled Trial,” Lancet 366
(2005): 225–33.

98 “But give it on time”: A. A. Gawande and T. G. Weiser, eds.,World
Health Organization Guidelines for Safe Surgery (Geneva: WHO,
2008).

102 “In one survey of three hundred”:M. A. Makary et al., “Operating
Room Briefings and Wrong-Site Surgery,” Journal of the American
College of Surgeons 204 (2007): 236–43.

102 “surveyed more than a thousand”: J. B. Sexton, E. J. Thomas, and R.
L. Helmsreich, “Error, Stress, and Teamwork in Medicine and
Aviation,” British Medical Journal 320 (2000): 745–49.

108 “The researchers learned”: See preliminary data reported in “Team
Communication in Safety,” OR Manager 19, no. 12 (2003): 3.

109 “After three months”: Makary et al., “Operating Room Briefings and
Wrong-Site Surgery.”

109 “At the Kaiser hospitals”: “ ‘Preflight Checklist’ Builds Safety
Culture, Reduces Nurse Turnover,” OR Manager 19, no. 12 (2003): 1–
4.

109 “At Toronto”: L. Lingard et al. “Getting Teams to Talk: Development
and Prior Implementation of a Checklist to Promote Interpersonal
Communication in the OR,” Quality and Safety in Health Care 14
(2005): 340–46.

6. THE CHECKLIST FACTORY
114 “Among the articles I found”: D. J. Boorman, “Reducing Flight

Crew Errors and Minimizing New Error Modes with Electronic
Checklists,” Proceedings of the International Conference on Human-
Computer Interaction in Aeronautics (Toulouse: Editions Cépaudès,
2000), pp. 57–63; D. J. Boorman, “Today’s Electronic Checklists



Reduce Likelihood of Crew Errors and Help Prevent Mishaps,” ICAO
Journal 56 (2001): 17–20.

116 “An electrical short”: National Traffic Safety Board, “Aircraft
Accident Report: Explosive Decompression—Loss of Cargo Door in
Flight, United Airlines Flight 811, Boeing 747-122, N4713U,
Honolulu, Hawaii, February 24, 1989,” Washington D.C., March 18,
1992.

116 “The plane was climbing”: S. White, “Twenty-Six Minutes of
Terror,” Flight Safety Australia, Nov.–Dec. 1999, pp. 40–42.

120 “They can help experts”: A. Degani and E. L. Wiener, “Human
Factors of Flight-Deck Checklists: The Normal Checklist,” NASA
Contractor Report 177549, Ames Research Center, May 1990.

121 “Some have been found confusing”: Aviation Safety Reporting
System, “ASRS Database Report Set: Checklist Incidents,” 2009.

129 “Crash investigators with Britain’s”: Air Accidents Investigation
Branch, “AAIB Interim Report: Accident to Boeing 777-236ER, G-
YMMM, at London Heathrow Airport on 17 January 2008,”
Department of Transport, London, Sept. 2008.

129 “ ‘It was just yards above’ ”: M. Fricker, “Gordon Brown Just 25
Feet from Death in Heathrow Crash,” Daily Mirror, Jan. 18, 2008.

129 “The nose wheels collapsed”: Air Accidents Investigation Branch,
“AAIB Bulletin S1/2008,” Department of Transport, London, Feb.
2008.

130 “Their initial reports”: Air Accidents Investigation Branch, “AAIB
Bulletin S1/2008”; Air Accidents Investigation Branch, “AAIB
Bulletin S3/2008,” Department of Transport, London, May 2008.

132 “Nonetheless, the investigators tested”: Air Accidents Investigation
Branch, “AAIB Interim Report.”

132 “So in September 2008”: Federal Aviation Administration,
Airworthiness Directive; Boeing Model 777-200 and -300 Series
Airplanes Equipped with Rolls-Royce Model RB211-TRENT 800
Series Engines, Washington, D.C., Sept. 12, 2008.

133 “One study in medicine”: E. A. Balas and S. A. Boren, “Managing
Clinical Knowledge for Health Care Improvement,” Yearbook of
Medical Informatics (2000): 65–70.



133 “almost 700,000 medical journal articles”: National Library of
Medicine, “Key Medline Indicators,” Nov. 12, 2008, accessed at
www.nlm.nih.gov/bsd/bsd_key.html.

134 “This time it was”: National Transportation Safety Board, “Safety
Recommendations A-09-17-18,”Washington, D.C., March 11, 2009.

7. THE TEST
139 “Of the tens of millions”: Joint Commission, Sentinel Event Alert,

June 24, 2003.
139 “By comparison, some 300,000”: R. D. Scott, “The Direct Medical

Costs of Healthcare-Associated Infections in U.S. Hospitals and the
Benefits of Prevention,” Centers for Disease Control, March 2009.

140 “The final WHO safe surgery checklist”: The checklist can be
accessed at www.who.int/safesurgery.

146 “We gave them some PowerPoint slides”: The videos can be viewed
at www.safesurg.org/materials.html.

156 “In January 2009”: A. B. Haynes et al., “A Surgical Safety Checklist
to Reduce Morbidity and Mortality in a Global Population,” New
England Journal of Medicine 360 (2009): 491–99.

8. THE HERO IN THE AGE OF CHECKLISTS
161 “Tom Wolfe’s The Right Stuff”: T. Wolfe, The Right Stuff (New York:

Farrar, Straus and Giroux, 1979).
163 “Neuroscientists have found”: H. Breiter et al., “Functional Imaging

of Neural Responses to Expectancy and Experience of Monetary Gains
and Losses,” Neuron 30 (2001): 619–39.

166 “ ‘Cort’s earning power’ ”: Wesco Financial Corporation, Securities
and Exchange Commission, Form 8-K filing, May 4, 2005.

170 “Smart specifically studied”: G. H. Smart, “Management Assessment
Methods in Venture Capital: An Empirical Analysis of Human Capital
Valuation,” Journal of Private Equity 2, no. 3 (1999): 29–45.

172 “He has since gone on”: G. H. Smart and R. Street, Who: The A
Method for Hiring (New York: Ballantine, 2008).



173 “A National Transportation Safety Board official”: J. Olshan and I.
Livingston, “Quiet Air Hero Is Captain America,” New York Post, Jan.
17, 2009.

174 “As Sullenberger kept saying”:M. Phillips, “Sully, Flight 1549 Crew
Receive Keys to New York City,” The Middle Seat, blog,Wall Street
Journal, Feb. 9, 2009, http://blogs.wsj.com/middleseat/2009/02/ 09/.

174 “ ‘That was so long ago’ ”: “Sully’s Tale,” Air&Space, Feb. 18,
2009.

178 “Once that happened”: C. Sullenberger and J. Zaslow, Highest Duty:
My Search for What Really Matters (New York: William Morrow,
2009).

179 “Skiles managed to complete”: Testimony of Captain Terry Lutz,
Experimental Test Pilot, Engineering Flight Operations, Airbus,
National Transportation Safety Board, “Public Hearing in the Matter of
the Landing of US Air Flight 1549 in the Hudson River, Weehawken,
New Jersey, January 15, 2009,” June 10, 2009.

180 “ ‘Flaps out?’ ”: D. P. Brazy, “Group Chairman’s Factual Report of
Investigation: Cockpit Voice Recorder DCA09MA026,” National
Transportation Safety Board, April 22, 2009.

180 “For, as journalist and pilot”: W. Langewiesche, “Anatomy of a
Miracle,” Vanity Fair, June 2009.

181 “After the plane landed”: Testimony of Captain Chesley
Sullenberger, A320 Captain, US Airways, National Transportation
Safety Board, Public Hearing, June 9, 2009.



ACKNOWLEDGMENTS

Three kinds of people were pivotal to this book: the ones behind the
writing, the ones behind the ideas, and the ones who made both possible. As
the book involved background research in several fields beyond my
expertise, the number of people I am indebted to is especially large. But this
book could never have been completed without all of them.

First are those who helped me take my loose observations about failure
and checklists and bring them together in book form. My agent, Tina
Bennett, saw the possibilities right away and championed the book from the
moment I first told her about my burgeoning fascination with checklists.
My editor at the New Yorker, the indispensable Henry Finder, showed me
how to give my initial draft more structure and my thinking more
coherence.

Laura Schoenherr, my brilliant and indefatigable research assistant, found
almost every source here, checked my facts, provided suggestions, and kept
me honest. Roslyn Schloss provided meticulous copyediting and a vital
final review. At Metropolitan Books, Riva Hocherman went through the
text with inspired intelligence and gave crucial advice at every stage of the
book’s development. Most of all, I leaned on Sara Bershtel, Metropolitan’s
publisher, with whom I’ve worked for nearly a decade now. Smart, tough,
and tireless, she combed through multiple drafts, got me to sharpen every
section, and saved me from numerous errors of tone and thinking, all the
while shepherding the book through production with almost alarming
efficiency.

As for the underlying ideas and the stories and experience fleshing them
out, I have many, many to thank. Donald Berwick taught me the science of
systems improvement and opened my eyes to the possibilities of checklists
in medicine. Peter Pronovost provided a crucial source of ideas with his
seminal work in ICUs. Lucian Leape, David Bates, and Berwick were the
ones to suggest my name to the World Health Organization. Sir Liam



Donald-son, the chair of WHO Patient Safety, who established the
organization’s global campaign to reduce deaths in surgery, was kind
enough to bring me aboard to lead it and then showed me what leadership
in public health really meant. Pauline Philip, the executive director of WHO
Patient Safety, didn’t take no for an answer from me and proved
extraordinary in both her dedication and her effectiveness in carrying out
work that has now extended across dozens of countries.

At WHO, Margaret Chan, the director general, as well as Ian Smith, her
adviser, David Heymann, deputy director general, and Tim Evans, assistant
director general, have all been stalwart supporters. I am also particularly
grateful to Gerald Dziekan, whom I have worked with almost daily for the
past three years, and also Vivienne Allan, Hilary Coates, Armorel Duncan,
Helen Hughes, Sooyeon Hwang, Angela Lashoher, Claire Lemer, Agnes
Leotsakos, Pat Martin, Douglas Noble, Kristine Stave, Fiona Stewart-Mills,
and Julie Storr.

At Boeing, Daniel Boorman emerged as an essential partner in work that
has now extended to designing, testing, and implementing clinical
checklists for safe childbirth, control of diarrheal infections, operating room
crises, management of patients with H1N1 influenza, and other areas. Jamie
and Christopher Cooper-Hohn, Roman Emmanuel, Mala Gaonkar and
Oliver Haarmann, David Greenspan, and Yen and Eeling Liow were early
and vital backers.

At the Harvard School of Public Health, the trio of William Berry, Tom
Weiser, and Alex Haynes have been the steel columns of the surgery
checklist work. The WHO Safe Surgery program I describe in this book
also depended on Abdel-Hadi Breizat, Lord Ara Darzi, E. Patchen
Dellinger, Teodoro Herbosa, Sidhir Joseph, Pascience Kibatala, Marie
Lapitan, Alan Merry, Krishna Moorthy, Richard Reznick, and Bryce Taylor,
the principal investigators at our eight study sites around the world; Bruce
Barraclough, Martin Makary, Didier Pittet, and Iskander Sayek, the leaders
of our scientific advisory group, as well as the many participants in the
WHO Safe Surgery Saves Lives study group; Martin Fletcher and Lord
Naren Patel at the National Patient Safety Agency in the U.K.; Alex
Arriaga, Angela Bader, Kelly Bernier, Bridget Craig, Priya Desai, Rachel
Dyer, Lizzie Edmondson, Luke Funk, Stuart Lipsitz, Scott Regenbogen, and



my colleagues at the Brigham and Women’s Center for Surgery and Public
Health; and the MacArthur Foundation.

I am deeply indebted to the many experts named throughout the book
whose generosity and forbearance helped me explore their fields. Unnamed
here are Jonathan Katz, who opened the door to the world of skyscraper
building; Dutch Leonard and Arnold Howitt, who explained Hurricane
Katrina to me; Nuno Alvez and Andrew Hebert, Rialto’s sous chefs, who let
me invade their kitchen; Eugene Hill, who sent me the work of Geoff
Smart; and Marcus Semel, the research fellow in my group who analyzed
the data from Harvard Vanguard Medical Associates showing the
complexity of clinical work in medicine and the national data showing the
frequency of death in surgery. In addition, Katy Thompson helped me with
the research and fact-checking behind my New Yorker article “The
Checklist,” which this book grew out of.

Lastly, we come to those without whom my life in writing and research
and surgery would be impossible. Elizabeth Morse, my administrative
director, has proved irreplaceable, lending a level head, around-the-clock
support, and continually wise counsel. Michael Zinner, the chairman of my
surgery department at Brigham and Women’s Hospital, and Arnie Epstein,
the chairman of my health policy and management department at the
Harvard School of Public Health, have backed me in this project as they
have for many others over the last decade and more. David Remnick, the
editor of the New Yorker, has been nothing but kind and loyal, keeping me
on staff through this entire period. I could not be more fortunate to have
such extraordinary people behind me.

Most important, however, are two final groups. There are my patients,
both those who have let me tell their stories here and those who have
simply trusted me to try to help with their care. I have learned more from
them than from anyone else. And then there is my family. My wife,
Kathleen, and children, Hunter, Hattie, and Walker, tend to suffer the brunt
of my mutating commitments and enthusiasms. But they have always found
ways to make room for my work, to share in it, and to remind me that it is
not everything. My thanks to them are boundless.



ABOUT THE AUTHOR

Atul Gawande is the author of Better and Complications. A MacArthur
Fellow, a general and endocrine surgeon at the Brigham and Women’s
Hospital in Boston, a staff writer for The New Yorker, and an associate
professor at Harvard Medical School and the Harvard School of Public
Health, he also leads the World Health Organization’s Safe Surgery Saves
Lives program. He lives with his wife and three children in Newton,
Massachusetts.