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The Checklist Manifesto

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"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."

— Atul Gawande, The Checklist Manifesto (2009)

Introduction

The Checklist Manifesto
Full titleThe Checklist Manifesto: How to Get Things Right
AuthorAtul Gawande
LanguageEnglish
SubjectPatient safety; Quality assurance in health care; Process improvement
GenreNonfiction; Self-help
PublisherMetropolitan Books (Henry Holt and Company)
Publication date
22 December 2009
Publication placeUnited States
Media typePrint (hardcover, paperback); e-book; audiobook
Pages224
ISBN978-0-8050-9174-8
Goodreads rating4/5  (as of 11 November 2025)
Websiteus.macmillan.com

The Checklist Manifesto argues that well-designed checklists help experts manage complexity, reduce avoidable errors, and deliver more reliable results in high-stakes domains from surgery to aviation and construction.[1] The book blends reportage and case studies in plain, New Yorker-style prose. It is organized as nine chapters that move from the problem of complexity to field tests and adoption.[2][3] Gawande situates the narrative in the World Health Organization’s Safe Surgery program and cites a 19-item surgical checklist study that cut major complications from 11.0% to 7.0% and deaths from 1.5% to 0.8% across eight hospitals.[4] The title reached the New York Times Hardcover Nonfiction list; for the week of 7 March 2010 it ranked No. 13.[5]

Chapters

Chapter 1 – The problem of extreme complexity

🧩 In Klagenfurt, Austria, a three-year-old submerged for thirty minutes in an icy fishpond arrived pulseless at 66°F with fixed pupils; a chain of specialists placed her on bypass, then ECMO, sewing lines directly into her aorta and beating heart. After intracranial pressure monitoring and round-the-clock ICU care, she went home two weeks later and made a full recovery by age five. Such saves require scores of people to execute thousands of steps in precise sequence—sterility, machine settings, airway care, staged rewarming—without missing a single one. In hospitals, this choreography is daily work: ICUs take over lungs, hearts, and kidneys while staff perform roughly 178 actions per patient per day; even a 1% error rate yields about two mistakes per patient. The scale is nationwide: about 90,000 people are in intensive care on any given day in the United States, five million annually, with an average four-day stay and an 86% survival rate. Outside the ICU, “ordinary” clinic work is no longer ordinary: physicians at Harvard Vanguard handle roughly 250 distinct primary conditions and 900 additional active problems per year, prescribe about 300 medications, order 100+ lab types, and perform 40 procedures—so many possibilities that even electronic records can’t keep up. Failures increasingly arise not from ignorance but from “ineptitude,” as when heart-attack patients miss the 90-minute door-to-balloon window because dozens of steps and handoffs slip. Specialization helps yet multiplies handoffs, and complexity outruns memory and vigilance. Reliability therefore depends on systems that make critical steps explicit at the right moment, widen attention at handoffs, and let teams coordinate under pressure rather than rely on recall.

Chapter 2 – The checklist

📝 On 30 October 1935 at Wright Field, Boeing’s Model 299—soon dubbed the “flying fortress”—rose smoothly, stalled at 300 feet, and crashed; nothing had broken, but the chief test pilot had forgotten to release a new control lock on the elevator and rudder. Test pilots answered with a terse index-card checklist for takeoff, flight, landing, and taxiing; with it, they flew 1.8 million miles without accident, and the B-17 entered mass production. Hospitals had their own quiet checklist in vital signs—temperature, pulse, blood pressure, respiration—but too often left simple all-or-none items undone when stress mounted. Peter Pronovost’s five-step central-line checklist at Johns Hopkins—soap, chlorhexidine, full drape, mask/hat/gown/gloves, sterile dressing—paired with explicit nurse authority cut ten-day line infections from 11% to zero and prevented 43 infections and 8 deaths in a year, saving about $2 million. Michigan’s Keystone Initiative scaled the idea: with executives fixing supply gaps (chlorhexidine, full drapes) and twice-monthly troubleshooting calls, ICUs reduced line infections by 66%, outperformed 90% of U.S. ICUs, saved an estimated 1,500 lives, and avoided $175 million in costs in 18 months. The pattern is consistent: brief, unambiguous checks at clear pause points plus team empowerment turn “dumb stuff” into disciplined reliability. These lists protect against memory limits and normalize speaking up, so the right things happen when cognitive bandwidth is thinnest.

Chapter 3 – The end of the master builder

🏗️ A new hospital wing and, a few blocks away, Boston’s Russia Wharf project show why the medieval “Master Builder” model is dead: modern projects involve sixteen trades, dozens of firms, and hundreds of workers—at Russia Wharf, a 32-story, 700,000-square-foot complex with 60 subcontractors and 200–500 workers on site daily, overseen by project executive Finn O’Sullivan and engineered by Joe Salvia’s firm. On the conference-room walls hang butcher-paper construction schedules—color-coded, day by day—one long checklist of pours, deliveries, and installs, printed and reposted weekly. Next to them sits the submittal schedule, a second checklist that forces communication—who must talk to whom, by when, about what—so unanticipated problems (like rain-pooled, inward-tilting upper floors from early core settling) get surfaced, discussed, and resolved together. Digital “Clash Detective” models reveal thousands of conflicts before they become field mistakes, and tools like ProjectCenter route photos and fixes to everyone who must sign off, with deadlines. The industry abandoned lone-authority heroics because complexity punishes autonomy; reliability comes from explicit task checks and mandated conversations that put many eyes on each uncertainty. The Citicorp episode—bolted joints substituted for welded ones, discovered late and fixed by emergency welds—underscores how a single missed communication can be catastrophic and how structured checks create second chances. Medicine can borrow the same approach: pair short “killer-item” checks with protocols that obligate teams to brief, cross-check, and adapt together.

Chapter 4 – The idea

💡 In Boston’s building trade, project executive Finn O’Sullivan manages risk by pushing decisions to the periphery and obligating communication, so inspectors and specialized crews coordinate fixes rather than wait for orders from a “master builder.” After Hurricane Katrina made landfall at 6:00 a.m. on 29 August 2005, Wal-Mart’s logistics teams routed water and food to refugees and even the National Guard a day before federal help arrived, eventually donating $3.5 million in merchandise to shelters and command centers, while local police and firefighters enlisted civilians with flat-bottom boats to rescue families from flooded streets. The point was not private versus public; complex situations punish command-and-control and reward a mix of freedom and discipline, where people adapt locally yet agree to common checks that force coordination and track progress. The entertainment world offered a vivid analogue: Van Halen’s contract clause requiring a backstage bowl of M&Ms with the brown ones removed functioned as a test of whether promoters had read the thousands of words of staging specs that, if missed, could collapse a floor. In each sphere, the checklist does not script every move; it exposes the critical items and confirms that the right conversations happen at the right time. This structure turns autonomy into organized reliability, spreading responsibility without losing control. When surprises hit, the checks create pause points where teams surface risks, verify resources, and align plans. That balance lets craft and protocol coexist, trapping preventable errors while preserving expertise. Industries from skyscraper construction to disaster response use the same pattern on ordinary days and on the worst days alike. Simple, explicit checks elevate teamwork by making accountability and adaptation visible. Reliability follows when power is dispersed but communication is required and measured. There must always be room for judgment, but judgment aided—and even enhanced—by procedure.

Chapter 5 – The first try

🧪 In Geneva, a World Health Organization working group set out to cut surgical harm worldwide and, hunting for a model, examined Stephen Luby’s 2005 Karachi experiment where HOPE field-workers delivered 3.3 bars of soap per week and taught when and how to wash hands; diarrhea in children fell 52 percent, pneumonia 48 percent, and impetigo 35 percent despite poverty and contaminated water. The team drafted a single, short Safe Surgery checklist with three pause points—Sign In before anesthesia, Time Out before incision, and Sign Out before leaving the operating room—embedding brief introductions, identity/site/procedure confirmation, antibiotic timing, equipment checks, and an open question for anticipated risks. Back in Boston, the prototype hit friction: the circulating nurse read boxes aloud while the room pressed forward, language proved ambiguous, steps ran long, and the tempo of care outran the paper. The day exposed a culture gap as much as a design gap; the list had to fit the rhythm of surgery and invite everyone’s voice without derailing flow. It also revealed where reliability was most fragile—handoffs, timing, and “obvious” items that were not obvious under stress. The team shifted to plainer wording, tighter timing (under a minute where possible), and a spoken briefing that normalized concerns from any rank. Success also hinged on local adaptation and leadership choices outside the checklist—supplies on hand, roles agreed, and permission for anyone to call the pause. A workable checklist would be less a script than a prompt for teamwork that catches the killer items before they cascade. Concentrate on decisive behaviors at specific moments and make them easy to do right; get the room talking early so attention widens before it narrows. Progress comes from iteration and culture as much as content. By the end of the day, we had stopped using the checklist.

Chapter 6 – The checklist factory

🏭 In Seattle, Boeing’s Daniel Boorman walked through the 787’s flight-operations library—scores of terse, yellow-tabbed cards—divided into normal and non-normal checklists that pilots can run in seconds at defined pause points. One entry begins when the DOOR FWD CARGO light comes on in flight, a warning shaped by a United Airlines 747 incident out of Honolulu to Auckland in which an electrical short unlatched a cargo door; the modern card tells crews to equalize cabin pressure before descent so a door won’t blow out, a step you’d never want to invent at altitude. In the simulator, the cards proved modest and focused, leaving out tasks better handled by training or judgment—talking to the tower, briefing the cabin—so the checks stayed swift and usable. On 17 January 2008, British Airways Flight 38 from Beijing lost thrust on final approach to London; after months of investigation, regulators suspected ice crystals in polar-cooled fuel could clog lines during sudden demand, and Boeing’s team distilled dense bulletins into a few cockpit steps. The distillation spread quickly across airlines, with local adaptation encouraged, and scarcely two months later a Delta 777 at 39,000 feet over Great Falls, Montana suffered an uncommanded rollback of the right engine; the crew pulled the updated card and the engine recovered, and 247 passengers continued without even noticing. The aviation pattern is relentless: define clear pause points; separate normal from non-normal; keep checks short, legible, and concrete; and test, trim, and retest until they work in the real world. For surgery, design for speed and use under stress, and write for professionals who already know the work. When new knowledge arrives, codify it in a prompt that spreads faster than memos or seminars. Reliability comes from cards that surface the few critical steps at the moment they matter and from a process that continuously trims complexity to what a team can execute. Adoption sticks when teams see that the cards protect expertise rather than replace it. Good checklists are, above all, practical.

Chapter 7 – The test

🧭 In Boston, a small public-health research team rebuilt a surgery checklist with aviation rules—clearer language, faster pace, and a DO-CONFIRM format—then staged a conference-room simulation with assigned OR roles and a clock to keep each pause under about sixty seconds. Responsibility to start the list moved deliberately to the circulating nurse, signaling that anyone could question the process and protecting attention when the pilot was busy. Lines that weren’t killer items were cut so the three pause points—before anesthesia, before incision, and before leaving the OR—would fit the tempo of real cases. A WHO pilot then enlisted eight disparate hospitals with permission to measure complications, deaths, and systems failures: University of Washington Medical Center (Seattle), Toronto General Hospital (Canada), St. Mary’s Hospital (London), Auckland City Hospital (New Zealand), Philippines General Hospital (Manila), Prince Hamza Hospital (Amman), St. Stephen’s Hospital (New Delhi), and St. Francis Designated District Hospital (Ifakara, Tanzania). Local leaders translated and adapted wording, stocked missing supplies like antibiotics in the OR, and launched with senior surgeons, anesthetists, and nurses to work out kinks. Early signals were concrete: in London a knee replacement paused when the prosthesis on hand proved the wrong size; in New Delhi antibiotic timing moved into the operating room when delays made pre-op doses wear off; in Seattle teams reported catching missed antibiotics, equipment issues, and overlooked medical risks. Across sites, complication rates fell after adoption, and in January 2009 the New England Journal of Medicine published the results as a rapid-release article. Momentum followed: hospitals in Washington State formed a coalition with insurers, Boeing, and the governor to roll out the checklist and track data, while in the United Kingdom, Lord Darzi and Sir Liam Donaldson launched a national campaign. Reliability grows when brief, explicit checks are tied to defined pause points and the authority to speak up is shared. Making performance visible and measurable turns a simple sheet into a system that teams can refine and own. This thing was real.

Chapter 8 – The hero in the age of checklists

🛡️ Hospitals spent billions on $1.7-million surgical robots that promised finesse but delivered only modest gains for a few operations, while a short WHO checklist quietly cut complications at a fraction of the cost. After the checklist’s results were 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—committed to national adoption, and hospital associations in twenty U.S. states pledged rollouts. By the end of 2009, about 10 percent of American hospitals had taken up the list or begun implementation, and more than two thousand hospitals worldwide were using it. Still, clinicians steeped in a “right stuff” culture resisted, much as test-pilot glamour yielded to checklists and simulators when aviation made danger manageable. In finance, investors reached similar conclusions: Mohnish Pabrai documented recurrent errors (his and Warren Buffett’s) and built roughly seventy written checks to guard against them, recognizing that memory and gut are selective under excitement or fear. A fund manager named Cook adopted a written checklist in early 2008; after an initial increase in front-end work, his team evaluated more investments faster and, by his account, rode out the crash with fewer missteps. Research by Smart on venture capital decision styles—Art Critics, Sponges, Prosecutors, and others—showed how codified prompts stabilize judgment across different temperaments. A few explicit questions at decisive moments widen attention, temper overconfidence, and make it easier to surface risks in public. Checklists do not replace audacity or expertise; they channel both so complex work becomes safer and more consistent. When autonomy meets shared discipline, performance improves without demanding superhuman memory. Try a checklist.

Chapter 9 – The save

🆘 As the checklist took shape in 2007, routine use in everyday cases produced immediate catches: a “Before Incision” pause held the knife until the antibiotic was actually in, a second pause averted giving an antibiotic to a patient who had refused it, and a quiet concern during a thyroid operation uncovered prior postoperative breathing trouble that prompted inhalers and overnight monitoring. The cumulative effect was visible organization—names spoken aloud, identity and side confirmed, warming blanket on, boots inflated, risks anticipated—so the room behaved like a unit rather than a set of strangers. Then came Mr. Hagerman, a fifty-three-year-old CEO with a right adrenal pheochromocytoma; during a laparoscopic adrenalectomy, a tear in the vena cava triggered torrential bleeding. The circulating nurse sounded an alarm and summoned help, the anesthesiologist poured in blood, additional access and equipment arrived, and a vascular surgeon was paged while the team watched the pressure trace and kept circulation going. More than thirty units were transfused—three times the patient’s blood volume—buying time to clamp and sew the hole and let the heart recover on its own. Weeks later, the patient was running again and back to rebuilding companies, grateful to be alive. These pauses prime swift mobilization, shared situational awareness, and permission for anyone to act on what they see. A checklist does not prevent every emergency; it makes a save more likely when the emergency comes. But when the knife hit the skin, we were a team.

—Note: The above summary follows the Metropolitan Books first U.S. hardcover edition (22 December 2009), ISBN 978-0-8050-9174-8.[1][2]

Background & reception

🖋️ Author & writing. Atul Gawande is a surgeon at Brigham and Women’s Hospital, a longtime staff writer at The New Yorker, and founder/chair of Ariadne Labs; his professional vantage point and reporting background shape the book’s voice and cases.[6][7] The project grew alongside the WHO Safe Surgery initiative, whose 19-item checklist underpins the book’s core case study and provides its empirical through-line.[8][9] Structurally, the book proceeds through nine chapter-length essays—on complexity, the checklist idea, testing, and scale-up—written in accessible narrative nonfiction.[2][10]

📈 Commercial reception. The Checklist Manifesto appeared on the The New York Times Hardcover Nonfiction list in early 2010; on 7 March 2010 it was ranked No. 13, indicating national bestseller-list visibility for the title and author.[11] Publisher materials also position Gawande as a New York Times bestselling author, consistent with his broader backlist performance.[1]

👍 Praise. Reviewers highlighted the clarity and storytelling that make a prosaic tool feel urgent. The Financial Times called it “a slim volume…packed with vivid writing [and] statistical surprises,” welcoming its case-driven argument for disciplined execution.[12] PBS’s NewsHour segment presented the book as a persuasive case for risk reduction in clinical practice, amplifying its public-interest appeal.[13] The The Guardian credited Gawande with showing how the “right kind of checklist liberates rather than stifles professional intuition,” noting his lucid style.[14]

👎 Criticism. Some commentators argued the book overgeneralizes from surgical settings to disparate fields; the Wall Street Journal review, for example, questioned the breadth of its claims beyond medicine.[15] Subsequent research has also produced mixed results on checklist impact at scale: a population-wide Ontario study found no significant change in operative mortality or complications after mandatory checklist adoption,[16] prompting an editorial on “the checklist conundrum” and the importance of culture and teamwork for sustained effect.[17] The The Guardian review likewise cautioned that, despite Gawande’s engaging narrative, the subject can feel prosaic and risks stretching a single organizing idea across too many domains.[18]

🌍 Impact & adoption. WHO reported large multicountry trials showing roughly one-third reductions in surgical deaths and complications with its checklist, and it now describes the tool as used by a majority of surgical providers worldwide.[19][20] Media coverage and professional outlets (e.g., AHRQ PSNet) helped translate the book’s argument into other safety-critical sectors, from law to construction, with hospitals and agencies citing it in patient-safety programs.[21][22]

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References

  1. ↑ 1.0 1.1 1.2 "The Checklist Manifesto". Macmillan. Henry Holt and Company. Retrieved 10 November 2025.
  2. ↑ 2.0 2.1 2.2 "The checklist manifesto : how to get things right (First edition)". WorldCat. OCLC. Retrieved 10 November 2025.
  3. ↑ "The checklist manifesto : how to get things right (table of contents)". Colorado Mountain College Library Catalog. Colorado Mountain College. Retrieved 10 November 2025.
  4. ↑ Haynes, Alex B.; Weiser, Thomas G.; Berry, William R.; Lipsitz, Stuart R.; Breizat, Abdel-Hadi S.; Dellinger, E. Patchen (29 January 2009). "A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population". The New England Journal of Medicine. 360 (5): 491–499. doi:10.1056/NEJMsa0810119. Retrieved 10 November 2025.
  5. ↑ "Hardcover Nonfiction – March 7, 2010" (PDF). Hawes Publications. 7 March 2010. Retrieved 10 November 2025.
  6. ↑ "Atul Gawande – Contributor page". The New Yorker. Condé Nast. Retrieved 10 November 2025.
  7. ↑ "Atul Gawande – Profile". Ariadne Labs. Ariadne Labs. Retrieved 10 November 2025.
  8. ↑ "WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives". NCBI Bookshelf. World Health Organization. 2009. Retrieved 10 November 2025.
  9. ↑ Haynes, Alex B.; Weiser, Thomas G.; Berry, William R.; Lipsitz, Stuart R.; Breizat, Abdel-Hadi S.; Dellinger, E. Patchen (29 January 2009). "A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population". The New England Journal of Medicine. 360 (5): 491–499. doi:10.1056/NEJMsa0810119. Retrieved 10 November 2025.
  10. ↑ "The checklist manifesto : how to get things right (table of contents)". Colorado Mountain College Library Catalog. Colorado Mountain College. Retrieved 10 November 2025.
  11. ↑ "Hardcover Nonfiction – March 7, 2010" (PDF). Hawes Publications. 7 March 2010. Retrieved 10 November 2025.
  12. ↑ "How lists of the 'dumb stuff' can save us from disaster". Financial Times. 6 January 2010. Retrieved 10 November 2025.
  13. ↑ "'Checklist Manifesto' Author Pairs Simplicity With Lifesaving". PBS NewsHour. 4 January 2010. Retrieved 10 November 2025.
  14. ↑ Behr, Rafael (23 January 2010). "The Checklist Manifesto by Atul Gawande and What Works by Hamish McRae". The Guardian. Retrieved 10 November 2025.
  15. ↑ Howard, Philip K. (23 January 2010). "Book Review: The Checklist Manifesto". The Wall Street Journal. Retrieved 10 November 2025.
  16. ↑ Urbach, David R.; Govindarajan, Anand; Saskin, Refik; Wilton, Andrew S.; Baxter, Nancy N. (13 March 2014). "Introduction of Surgical Safety Checklists in Ontario, Canada". The New England Journal of Medicine. 370 (11): 1029–1038. doi:10.1056/NEJMsa1308261. Retrieved 10 November 2025.
  17. ↑ Leape, Lucian L. (13 March 2014). "The Checklist Conundrum". The New England Journal of Medicine. 370 (11): 1063–1064. doi:10.1056/NEJMe1315851. Retrieved 10 November 2025.
  18. ↑ Behr, Rafael (23 January 2010). "The Checklist Manifesto by Atul Gawande and What Works by Hamish McRae". The Guardian. Retrieved 10 November 2025.
  19. ↑ "Checklist helps reduce surgical complications, deaths". World Health Organization. 11 December 2010. Retrieved 10 November 2025.
  20. ↑ "WHO Surgical Safety Checklist – Tool and resources". World Health Organization. Retrieved 10 November 2025.
  21. ↑ "The Checklist Manifesto: How to Get Things Right". AHRQ Patient Safety Network. Agency for Healthcare Research and Quality. 13 January 2010. Retrieved 10 November 2025.
  22. ↑ "Captain of the Checklist". The New Yorker. 18 October 2009. Retrieved 10 November 2025.
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