The Checklist Manifesto: Introduction

Attention: Spoilers ahead. This post supposes that you have already read at least the Introduction from The Checklist ManifestoSee the proposed reading calendar here.

Of course, if you don’t plan to read it later and just want a brief introduction to the text, go ahead as well. 


This introduction works basically as a teaser to make you read the rest of the book. Anyone that has seen House knows how thrilling doctor stories can be. Gawande starts with two medical anecdotes with short sentences, building tension, step by step. 

Next he describes the text that propel him to consider why such mistakes happen: an essay by philosophers MacIntyre and Gorovitz in which they present the three main sources of error:

 i) necessary fallibility in those spheres that are beyond our capacity -like say stopping an earthquake to happen.

ii) ignorance. We don’t know enough about the world in order to make a proper action (like a meteorologist making a wrong prediction about next weekend weather because nowadays weather models are far from perfect)

iii) Ineptitude. We have the knowledge to make the right action, but we fail because we don’t apply it correctly.

The author then points out how our modern society has been moving from ignorance based mistakes to the ones that are a result of ineptitude. As our society has developed better knowledge and technology, we have created a much more complex world: things have to be done real quick, being sure that everything is done correctly, so  failure is a lot more probable. Gawande gives striking numbers: 

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.  

The problem can be found anywhere; not just in medicine. And it is not simply lack of training and practice, as the initial anecdotes with best-trained doctors show. 

So, in every field, we have a similar problem. We have created an immense amount of know-how that is very difficult to manage. The author then clearly poses the problem that the book aims to analyze and solve:

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. 

And the solution to this problem is not a new fancy technology, or an amazing breakthrough in management science, it is our humble checklist.



14 thoughts on “The Checklist Manifesto: Introduction

  1. Thank you David for this detailed review of the introduction of the book which lefts not much to add.

    I just wanted to comment that an introduction to a book in our modern times is expected to achieve two goals: first, declaring and defining clearly which is the subject of the book and, second, fascinating the exploratory reader so that he/she will buy and read the whole book. This introduction accomplishes perfectly both goals.

    I cannot imagine myself, after reading the last sentence of the introduction

    It is a checklist

    dropping the book and reading no more.

    We will have plenty of opportunity when reading next chapters to go in depth into the concepts suggested in the introduction.

    • Sorry, I’m slightly behind the reading schedule… The introduction is very well written, I hope the whole book is like that, my expectations are high now. The last sentence made me curious – how can checklist health? The surgeons did follow a certain procedure (so a checklist?) and still failed (or almost failed).

      • Hi Ela,
        wellcome to our joint reading. The last sentence is written just with that goal in mind: to make you curious without giving you details. The answers to your questions constitute the content of the rest of book. Be patient 🙂

          • Interesting paper, and lovely the connection with Swift’s “Modest proposal”.
            Satire is probably the less understood genre in history. The superb and dark satire of Gulliver’s Travels has become a book for children. When people discuss “Brave New World” they take it at face value, as if some sort of exploration of what the future will bring, when it is actually a satire.
            I am looking for a sarcastic sentence to finish this comment, but I can’t think of one…;-)

          • This paper is dangerous. A randomized trial is the ONLY real way to be sure of the causal relationships between variables. The fact that a randomized trial is not possible does not mean that we have to accept as true what common sense and intuition suggest. Our intuitions are wrong very often. What it really means is that we are not going to be ever sure of what those causalities are. And no matter how frustrating that may seem, we have to accept to live in acknowledgement of our deep ignorance.

            And, by the way, I was tempted to write:
            – satire? I can’t see any satire in the book.
            But probably somebody would have answered to me:
            – Carlos, you wouldn’t see satire if it painted itself …

            • I’ve written my last comment after reading only the introduction. How can a checklist be a solution? You’re right the last sentence of the introduction and the book title should be probably intriguing rather than satirising.
              Re RCTs we can/should acknowledge our ignorance but the question is whether to do nothing or to trust the intuition.

              • Re RCTs? I don’t follow your acronyms 🙂
                I am a big fan of doing nothing but this, however, goes against human psychology. Imagine that you have a child that catches a cold. You have to decide to go or not to see the doctor. If you make some Bayesian reckoning you see that the probabilities of your child getting harm from a wrong diagnosis, a badly done procedure or just catching something worse from another sick child while in the waiting room of the doctor are much higher than the probabilities that your child have one of those rare diseases that are going to kill him if he doesn’t receive immediate medical help.
                You should decide to stay at home, but you don’t. Why?
                Because if you go to the doctor and something goes wrong you feel that it is because of the doctor, the nurse, that other child or just bad lack. If you stay at home and the child dies you will consider that it is your fault.
                See the irony here, you do something that is WORSE for your child just to avoid the unbearable feeling of being responsible for his death.

                • Apologies for my medical jargon (I meant regarding randomised control trials). Most of us don’t calculate probabilities of each possible event. Usually we have to deal with too many unknown parameters. Why not to trust our intutition in such cases? Relying on the intuition is not the same though as searching for someone to blame.

  2. Pingback: Synchronized Reading Begins | El Pla Subtil

  3. 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. (p 10)

    The numbers are really shocking. And we are not prepared psychologically to accept this kind of errors:

    Such failures carry an emotional valence that seems to cloud how we think about them. Failures of ignorance we can forgive. (…) 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 patiens don’t get their treatment on time? What do you mean that two-thirds of death penalty cases are overturned because of errors?
    (p 11)

  4. Pingback: Human Factors | El Pla Subtil

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