The Checklist Manifiesto: The First Try

(Our weekly reading according to our reading calendar)

Atul Gawande is approached by the World Health Organization (WHO) to integrate into group of people trying to develop a global program to reduce avoidable deaths and harm from surgery.

The magnitude of the enterprise, because of the thousands of different medical procedures available, the millions of operations performed every year and the poor and ill equipped environments where some of such operations were taking place, overwhelms the author to the point that he believes that not much can be done.

Training programs and incentive approaches are out of the question because of practicability and funding issues. The only possible solutions can be very low tech and simple actions. It explains the example of a successful program against cholera and other water borne diseases in Pakistan which gave free bars of soap to the families and gave them a list of six situations when they have to wash their hands.

The secret, he pointed out to me, was that the soap was more than soap. It was a behavior-change delivery vehicle. (p. 96)

It was a checklist!

And so they consider the possibility of creating some checklist to encode a set of good practices for the surgery rooms. The author reviews some independent developments of 3 hospitals in US and Canada that had developed successful checklist to be used during surgery. He gives us an insight of the main issues that such checklists should take into account and how the hospitals were coping with them:

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 (…)

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. (…) 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. (p. 101)

And here we come to the two central ideas of this chapter. First, the only way to cope with the unexpected is by communication and team work. Second, team work can be improved by the use of some simple rules. It is not a question of luck and finding the right people, is something that can be worked on.

So there are checklists to do the routine work without missing steps and checklists to light up the engines of creativity, communication and cooperation within a team.

So they knew what they have to do. They create a perfect checklist for the perfect surgery and organize some hospitals in the world to put it to a test. Before doing that, however, Gawande wants to try it himself at his hospital. And it doesn’t work. The checklist just creates confusion and has to be abandoned.

And the chapter ends here.


One thought on “The Checklist Manifiesto: The First Try

  1. Thank you so much for this detailed and clear review, Carlos.
    The thing that surprised me more the first time I read this chapter is how surgery is still considered a solo performance thing, and the decisions of the surgeon are not supposed to be discussed by the rest of the team.
    I also found very interesting to find out that it is easier to work with a new team if you know their names. So simple and easy, but seems to imply relevant improvements in the task at hand.
    In this chapter again, Gawande knows how to create tension and emotion; the description of the operation of the eighty years man with a partially gangrened intestines works like a thriller and almost turns gore in some places.
    And the end of the chapter is really superb. We’ve been told how awesome checklist are, we’ve seen then in action for building skyscrapers and now, when they are tried in surgery… Don’t seem to work! What went wrong?

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