THE CHECKLIST MANIFESTO - Atul Gawande - Nonfiction

How are great ideas spread? Judging by the progress of social media over the past five years, you might say that facebook and twitter are the easiest ways to get a message out. But Atul Gawande is going back to the grand tradition of the pamphlet--or, in this case, the slim (less than 200 pages) manual for change. Gawande's causes in the past have been the medical education of the public, and the promotion of better surgical standards and practices, and here he hews close to his beaten path, championing the cause of, as he says, "the humble checklist." As an aid to surgical improvement, it might easily be overlooked, but his carefully compiled and cross-checked statistics make a convincing case for its indispensability at the operating table.

Checklists, as Gawande notes in a number of chapters, are used successfully to govern many of the complicated procedures we engage in as a society. On airplanes (and space shuttles), in construction projects, restaurant kitchens, and disaster response, checklists are already used with great success and acceptance. Surgery, however, doesn't have a good system in place for making sure that commonplace errors--errors which, crucial to Gawande's position as the WHO's point man for safe surgery worldwide, happen no matter where the surgery is taking place, or who is performing it--are discussed and prevented. Gawande shares some horror stories in his introduction, contributed by a friend of his working at a hospital in San Francisco. In one case, a patient was given an accidental overdose of a common supplement, and it stopped his heart on the operating table. In another case, a man's stab wound was dangerously ignored because doctors assumed it was caused by a short-bladed knife, when it was in fact caused by a bayonet-wielding halloween partier. In other, more commonly discussed cases, surgical tools or sponges are accidentally left inside patients, patients are given the wrong procedure, or given surgery on the wrong side of the body, or proper preparation is not carried out, and blood supplies or crash carts are not available. Anyone who has ever planned a birthday party or organized an international trip will know that the easiest way not to forget something is to write it down--and cross it off. And, Gawande proposes, this is exactly what medicine needs to do: come up with a short, simple checklist, to be implemented at three stages during the surgical procedure, involving simple checks and announcements of information meant to streamline and verify the operation.

This is not exactly reinventing the wheel, and clinical trials at individual hospitals, as well as WHO's Gawande-led efforts worldwide, have shown the efficacy of such a checklist. In fact, the people Gawande blames for impeding the implementation of surgical checklists are surgeons themselves. According to the author, one of the most renowned surgeons in the country, surgeons are pompous and proud, slow to change and easy to offend. Tell a surgeon that his quality of surgery will improve by using a checklist that asks everyone to agree upon what procedure will be performed, what the patient's medical details are, and whether the blood bank has been informed of the surgery, among other items, is apparently akin to asking a professional baseball player to confirm, before each game, that he intends to run the bases counter-clockwise. And yet, although baseball players never run the wrong way, the sheer amount of information that a doctor must keep in his head at once ensures that mistakes do happen, tools are left inside sutured incisions, and checklists can, and do, save lives. Gawande admits that even he was reluctant to use the checklist, thinking that his surgeries could hardly be better, but saw significant improvements when he did, and in all likelihood avoided killing a patient when an improbable mistake required immediate access to extra liters of blood.

The descriptions of all these near-death experiences deliver more chills per minute than a Stephen King novel, and Gawande knows exactly what he's doing. By tapping into our emotional responses to his idea, he is taking a checklist from a bureaucratic time-wasting device to an essential upgrade in life-saving technology: exactly what hospital administrators need to believe, and surgeons need to demand. A number of countries have already instituted checklists in every hospital, at every surgery, although the U.S. has not--perhaps something to ask for in healthcare reform?--and it would be good advice to ask your surgeon, if you can, whether he intends to use a checklist for your surgery…and to strongly suggest that he or she does.