Introduction

Have you ever seen an emergency operation take place on TV or in real life? Were you ever fascinated by how well-coordinated the doctors and nurses were? Did it make you wonder how people do this?In this book, you’ll learn about the power of checklists. Even if it seems very basic, you will learn how professionals like doctors and pilots use checklists as much as possible. This simple technique has proven time and time again to be effective and life-saving.You’ll also learn about the difference between good checklists and bad ones. This book will teach you how to make your own checklists that can aid you in your work.No matter what career you are in or training you have, you can become overwhelmed with all the work you are responsible for. This book will teach you how a simple checklist can make things easier and simpler. With practice, you will avoid mistakes and do each task successfully and avoid forgetting important steps.

The Problem of Extreme Complexity

A medical journal described a case study which caught author Gawande’s attention. The report described a family having a leisure walk in the woods when the parents lost sight of their three-year-old daughter. It was only three-seconds, but in that short time, the child fell into an icy pond. Her parents looked for her, and after thirty minutes they found her unconscious and frozen in the water.Even though they were panicking, the parents managed to call the emergency response team. While waiting for the team to arrive, the parents kept giving their daughter CPR. When the response team observed the girl’s condition, the outlook was grim: the three-year-old wasn’t responding at all. There was no pulse nor any sign of breathing. When they flashed a light on her eyes, she didn’t react to it. This was a sign that the brain wasn’t functioning anymore. Coldwater and debris from the pond had filled her lungs; she looked like she was gone.

But the response team ordered a helicopter to take the child to the nearest hospital. As she was being transported, the emergency crew continued performing CPR on her. Once they arrived, a surgical team planned to attach her to a heart-lung bypass machine. This machine would keep pumping blood into her, as her heart and lungs are not functioning anymore.The surgeon cut through the skin on the child’s groin and attached a silicone rubber tube into an artery. This tube would take the girl’s blood out of her while another silicone tube was attached to a vein and sent the blood back into her body.Right up to the point when she was plugged into the bypass machine, the girl had been lifeless for one hour and a half. But with blood flowing into her veins, her temperature began to rise and her heart started to beat once more.The child’s lungs were damaged because of dirty pond water, and the doctors found twigs, dirt and other objects inside of her lungs. Because of this, her lungs couldn’t pump oxygen into her body. So, the medical team used an artificial lung system that could pump oxygen for her. The team opened her chest with a power saw and inserted lines from the system to her lungs and heart.

Through the following night and day, the team performed fiberoptic bronchoscopy on the little girl. This meant that they removed the water and other objects from her lungs. The next day, the child’s lungs slowly recovered.Meanwhile, the child’s brain was also swelling, but the team managed to get that under control, too. For more than a week, the child was comatose. But after a few more weeks, all her organs were repaired and functioning, and she recovered.The whole team behind her recovery were like superheroes, don’t you think? It was as if they brought the three-year-old girl back from the dead. What the team did was extremely complicated. Not a single person could have done everything on their own, which made it more impressive, because many people had to work together to make sure every step of every single, complex operation would be perfect. Can you imagine the level of coordination required to accomplish this? Not to mention, this wasn’t the only case they were working on. Every person on the team had other tasks, too.

Despite that these professionals are experts in their fields, there is no denying that there are sometimes errors.There are more than 150,000 deaths every year concerning surgery. Studies have shown that at least 50% of these 150,000 deaths could have been avoided. For example, a member of the medical team might have forgotten to wash their hands or wear a face mask, or a tool may not have been properly sanitized and therefore led to a surgical infection.Even though they are professionals with lengthy training, they can still miss an important step. So, how do we combat this? How can we save more lives?

The Checklist

During the 1930s, the US Military Air Corps held a competition as to which airplane manufacturer would be their official supplier. The plane that Boeing brought to the competition was their best ever. It was a sight to behold: the Boeing 299 had a 103-foot wingspan and instead of two engines, it had four. It lifted smoothly off the ground and climbed to about 300 feet in the air. Boeing almost got the deal. But after a few minutes, the plane stalled and burst into flames. Out of the five crew members in the plane, two died, including the pilot.An investigation was launched and it was discovered that there was nothing wrong with the plane itself. The report concluded that the tragedy happened because of an error made by the pilot. The aircraft had complex engines, landing gear, and other high-tech features. Because he had to attend to a lot of controls, the pilot forgot to do just one crucial step. This led to the plane’s explosion and his own death. In the end, the Air Corps went for Martin and Douglas Company, but the army still purchased a few planes from Boeing.

Some people were convinced that the Boeing 299 was definitely flyable. So, test pilots set out to prove this, but they started with a different, yet surprisingly smart approach. The new team created a pilot’s checklist. For people who are experienced in flying airplanes, it could just be a hassle. The checklist was unnecessary! It was like having a checklist on how to get the car out of your garage. But the Boeing 299 was a complex plane. It was too complicated to be left to the memory of just one person, even if that person was an expert.The pilot’s checklist was simple and straight to the point. It was a step-by-step guide for pilots to follow for take-off, flight and landing.  Yes, it sounded like such an unnecessary thing to do. After all, pilots wouldn’t be pilots if they don’t know how to fly a plane, right? You’d think that the checklist would not make any difference, but it did. The pilot who used a checklist managed to fly the Boeing 299 for many miles without a single accident.

Most professional fields today are complex. Think of a dentist performing a root canal, or a surgeon doing a heart transplant. It can be difficult for people to do their jobs by relying only on their memory. Our memories are faulty. When we get used to a routine, we often forget or skip a step. We don’t do it on purpose, but our minds focus on the things that are new or urgently need our attention. We think that just because one step is simple, skipping it won’t matter. Until one day it does, and we or someone else suffers the consequences. Checklists help us to remember these boring, yet important steps. Checklists emphasize why these steps are there in the first place.In 2001, Peter Pronovost, a critical care specialist at John Hopkins Hospital, tried out a checklist for doctors. He decided to focus on one of the risks that a doctor can bring to a patient, which involved infecting central lines.Central lines are catheters that are inserted in the veins of a patient when the heart, kidney, or lungs, have failed. The lines are connected to a bypass or dialysis machine so that the patient remains stable, even if the major organ is not functioning. If a doctor forgets just one step in the process of inserting central lines, then germs go directly into the patient’s bloodstream and infect his or her internal organs.

On a sheet of paper, Pronovost listed out the protocol for setting up central lines. Just like the pilot’s checklist, this list was simple. If you were a doctor who had been practicing for years, you’d laugh at the checklist. You could easily go through the protocol with your eyes closed.Here was the checklist: first, wash your hands with soap.Second, clean the patient's skin with antiseptic. Third, put sterile drapes over the patient's whole body. Fourth, wear a sterile surgery gown, hat and face mask. Fifth, place a sterile dressing on the insertion area once the central line is inside the patient's vein.Pronovost asked the nurses to observe if the doctors followed every step in the checklist for a month.

The results were surprising: doctors would skip at least one basic step in every one out of three patients.The administration at the John Hopkins Hospital made it clear that if a doctor skipped a step, the nurse could stop them during the procedure and point it out. However, if the doctor didn't listen, the nurses would have the administration as a backup. For a year, the checklist was enforced.Pronovost and his colleagues were shocked at the results. After the checklist was implemented, the number of infections from central lines decreased from 11% of patients (having an infection every 10 days) to 0%! For another 15 months, the hospital observed patients who had the procedure. During this time, only two of them had a central line infection. Based on the team’s calculations, the checklist did wonders. It prevented 43 infections, 8 deaths, and saved the hospital about $2,000,000.