The Checklist Manifesto

The Checklist Manifesto Plot Summary

Introduction

In today's increasingly complex world, even experts regularly fail at what they do. A renowned surgeon makes an inexplicable error during a routine procedure. An experienced pilot misses a critical safety check. A veteran investor overlooks an obvious warning sign. Why do such failures occur despite deep expertise and the best intentions? The answer lies not in lack of knowledge or commitment, but in the overwhelming complexity that characterizes modern professional life. When tasks become too intricate, when responsibilities multiply, and when the unexpected constantly emerges, our unaided human abilities reach their limits. Our memories falter. Our attention wanders. We skip steps we know are important. But there exists a remarkably effective yet underutilized tool that can dramatically reduce these failures. Simple, well-designed checklists have proven capable of preventing catastrophic errors in fields ranging from aviation to construction to medicine. By forcing us to pause and verify essential actions, by encouraging teamwork, and by creating a higher standard of baseline performance, checklists offer protection against the inevitable failures of human memory and attention in an age of overwhelming complexity.

Chapter 1: Why We Fail: Understanding Human Error in Complex Systems

Human failure comes in two fundamental forms: failures of ignorance and failures of ineptitude. For most of history, we failed primarily because we didn't know enough. People died from diseases we didn't understand and couldn't treat. Buildings collapsed because we didn't comprehend the laws of physics well enough to build them properly. Our failures stemmed from gaps in our knowledge. Consider the case of a three-year-old girl who fell into an icy Austrian pond. By the time her parents found her, she had been underwater for thirty minutes. She was pulled from the water with no pulse, no breathing, and a body temperature of just 66 degrees. By conventional standards, she was dead. Yet a rescue team performed CPR while transporting her to a nearby hospital, where surgical teams connected her to heart-lung bypass machines to warm her blood gradually. After six hours, her body temperature normalized. Though her lungs remained damaged, she was switched to a different machine that could oxygenate her blood. Day by day, her organs recovered. First her pupils began responding to light, then she started breathing independently, and finally, she simply woke up. Two weeks later, she went home, completely recovered. This miraculous rescue wasn't simply the result of medical knowledge. It succeeded because dozens of people executed thousands of precise steps in perfect sequence without error. They placed tubes without introducing air bubbles, maintained sterility across multiple environments, balanced complex machinery, and coordinated their efforts seamlessly. Each individual step might seem simple, but the collective complexity was staggering. Today, such complexity permeates nearly every profession. A typical doctor at a community clinic may address 250 different primary diseases annually while managing 900 other active medical problems. They might prescribe 300 medications, order 100 different types of tests, and perform 40 distinct office procedures. Even everyday medical care has become too complex for any individual to execute flawlessly from memory alone. This new reality represents a fundamental shift. The primary challenge in most professional fields is no longer ignorance but ineptitude—not that we don't know what to do, but that we fail to apply what we know correctly, consistently, and precisely. Science has given us tremendous capability to tackle complex problems, but the volume and complexity of our knowledge has exceeded our unaided human ability to deliver its benefits reliably. The solution isn't simply more training or harder work. Even the most experienced professionals working at their best will sometimes fail when faced with sufficient complexity. What we need instead is a different strategy altogether—one that acknowledges our human limitations and compensates for them. We need cognitive nets to catch our mental flaws of memory, attention, and thoroughness. We need checklists.

Chapter 2: Creating Your First Checklist: Principles and Design

A checklist is fundamentally a tool to ensure consistency and completeness in carrying out a complex task. However, not all checklists are created equal. The difference between an effective checklist and a useless one lies in understanding core design principles that aviation and other high-reliability industries have perfected over decades. Daniel Boorman, a veteran pilot who spent twenty years developing checklists for Boeing aircraft, explains that good checklists share specific characteristics. They are precise, efficient, and easy to use even in the most difficult situations. Rather than trying to spell out every step—which would be impractical and counterproductive—they provide reminders of only the most critical and easily missed steps. They are practical above all else. Consider the design of an aviation checklist for handling a cargo door warning light. This might indicate a dangerous situation where a door could blow open at high altitude, causing catastrophic decompression. The checklist doesn't attempt to explain the physics of pressure differentials or the mechanics of door latches. Instead, it provides exactly what the crew needs: a sequence of steps to reduce cabin pressure safely, descend to a safe altitude, and manually secure the door. The language is precise and familiar to pilots. The format is clean and uncluttered. Each step is essential—neither more nor less than what's required to handle the emergency. When creating your own checklist, Boorman advises several crucial decisions. First, identify a clear pause point—the moment when the checklist should be used. Second, choose between two formats: DO-CONFIRM (where people perform tasks from memory, then pause to verify completion) or READ-DO (where people carry out tasks as they check them off). Third, focus on the "killer items"—steps that are both crucial and frequently missed. Fourth, keep it short, ideally between five and nine items, which is the limit of working memory. The wording should be simple and exact, using familiar professional language. The physical design matters too—it should fit on one page, remain free of clutter and unnecessary colors, and be easily readable under stress. Even font choice matters (sans serif types like Helvetica are recommended for visibility). Perhaps most importantly, every checklist must be tested in realistic conditions. First drafts inevitably fail. They must be revised based on real-world feedback until they work consistently. In aviation, this happens in simulators like the one Boorman demonstrated, where pilots can practice emergency procedures safely. Medical checklists likewise require rigorous testing in clinical settings before implementation. The ultimate test of a good checklist is whether it helps real people in the real world. When British Airways Flight 38 experienced dual engine failure on approach to Heathrow in 2008, investigators eventually discovered that ice crystals had formed in the fuel system during an extremely cold polar flight. Within weeks, Boeing had created a new checklist for this previously unknown problem. Just months later, when a Delta flight experienced the same issue over Montana, the pilots used the new checklist and resolved the problem so smoothly that passengers never realized they had narrowly averted disaster. Good checklists do more than prevent failure—they establish a higher standard of baseline performance and enable people to get the stupid stuff right consistently so they can focus on the hard, creative parts of their jobs.

Chapter 3: Implementing Checklists: Overcoming Resistance

Even the most brilliantly designed checklist is worthless if people won't use it. Across professions, the implementation of checklists frequently encounters significant resistance despite compelling evidence of their effectiveness. This resistance stems from deeper psychological and cultural barriers that must be systematically addressed. When the World Health Organization developed a surgical safety checklist to reduce complications and deaths, they piloted it in eight hospitals across the globe. These ranged from high-resource institutions like the University of Washington Medical Center to St. Francis Hospital in rural Tanzania, where surgeons worked with severely limited supplies and equipment. Despite dramatic differences in resources and conditions, researchers encountered similar resistance everywhere. "This checklist is a waste of time," was a common response. Many surgeons were offended by the very suggestion that they needed such a tool. They viewed checklists as an insult to their expertise, training, and autonomy. After all, these were professionals who had spent years honing their craft, often working 80-hour weeks during residency. They had cultivated a professional identity based on individual excellence and mastery—the capacity to handle complexity through sheer ability and concentration. Dr. Tom Piskorowski at Sinai-Grace Hospital in Detroit expressed what many felt: "Forget the paperwork. Take care of the patient." This sentiment captures a fundamental misunderstanding about checklists. They aren't bureaucratic hurdles that interfere with care; they're tools that enhance it by freeing mental bandwidth for the truly difficult aspects of professional work. The implementation strategy proved crucial. Rather than forcing compliance, the WHO team asked hospital leaders to identify respected physicians who would try the checklist first. When a prominent orthopedic surgeon in London discovered that using the checklist prevented him from operating on a patient with the wrong-sized knee prosthesis, he became an instant convert and advocate. Such positive experiences helped overcome initial skepticism. In India, using the checklist revealed a systemic problem in antibiotic administration. Staff had been giving antibiotics in the preoperative waiting area, but delays meant the medication often wore off before surgery began. Recognizing this through the checklist process allowed them to change their procedures and dramatically reduce infections. The resistance to checklists reveals something profound about professional culture. We have an image of expertise that involves complete mastery and autonomy—a "master builder" model that no longer matches the complexity of modern work. Aviation has explicitly rejected this model in favor of standardized procedures and teamwork. Other professions, including medicine, finance, and law, are just beginning this transition. Perhaps the most powerful evidence for overcoming resistance came from the WHO study results. After implementing the checklist, major complications fell by 36 percent and deaths by 47 percent across all eight hospitals. These improvements occurred not just in resource-poor settings but in top facilities as well. When surveyed afterward, 80 percent of staff reported that the checklist was easy to use and improved safety. But the most telling statistic was this: when asked if they would want the checklist used if they were having surgery themselves, 93 percent of staff—including many who had initially resisted—said yes. This gap between professional identity and personal preference reveals how we must reframe checklists not as threats to expertise but as tools that enable it.

Chapter 4: Turning Protocols into Teamwork

The power of a checklist extends far beyond preventing simple oversights. When properly designed, checklists can transform how people work together, creating teams out of individuals and improving how they handle both routine and unexpected challenges. This transformation of teamwork may be their most profound benefit. Brian Sexton, a Johns Hopkins psychologist, has documented the teamwork gap in operating rooms. When surveyed about teamwork quality, 64 percent of surgeons rated it highly, while only 39 percent of anesthesiologists, 28 percent of nurses, and a mere 10 percent of anesthesia residents agreed. This disconnect reflects the reality that many "teams" in medicine are collections of specialists working in parallel rather than truly collaborating. The WHO Safe Surgery Checklist addressed this problem by incorporating specific elements to foster teamwork. Before starting, all team members introduce themselves by name and role. This seemingly trivial step has powerful effects. Sexton's research shows that when surgical staff know each other's names, their communication ratings jump significantly. The checklist also requires a team briefing where the surgeon, anesthesiologist, and nurses each share their concerns and expectations for the case. At Toronto General Hospital, researchers documented how this brief communication could avert potential disasters. In one case, they recorded a pre-surgery conversation about a patient with a severe neurological condition that prevented verbal communication. The patient communicated through hand signals, but standard procedure would have restrained his arms during surgery. Because of the checklist-prompted discussion, the team realized this would prevent the patient from signaling pain during the procedure. They modified their approach, leaving his arms accessible while protecting the sterile field. The teamwork benefits extend beyond preventing errors. A surgeon described how using the checklist changed the dynamics in her operating room: "We just work better together as a team." This echoes findings from the aviation industry, where checklists have long been recognized as tools for coordinating complex activities among specialists who may never have worked together before. Consider US Airways Flight 1549, which Captain Chesley "Sully" Sullenberger successfully landed on the Hudson River after a bird strike disabled both engines. While Sullenberger received public acclaim as a lone hero, he consistently emphasized: "This was a crew effort." Before takeoff, the crew had run through their checklists and briefings, transforming five individuals who had never worked together into a cohesive team. When crisis struck, this preparation allowed them to coordinate seamlessly despite having just 208 seconds from bird strike to water landing. The checklist had activated their sense of shared responsibility and collaborative problem-solving. Sullenberger focused on flying and finding a landing site, while First Officer Skiles worked through engine restart procedures. Flight attendants executed the emergency evacuation perfectly. The result was that all 155 people aboard survived. Implementing teamwork-oriented checklists requires understanding that they involve a shift in authority and expectations. They distribute power and responsibility rather than concentrating it. In surgery, having nurses call a pause for the checklist challenges traditional hierarchies but ultimately benefits everyone. The checklist becomes a tool for democratic engagement rather than autocratic control. For organizations seeking to implement checklists successfully, this cultural dimension is essential. Leaders must model checklist use themselves, emphasize its value for teamwork rather than compliance, and create psychological safety for all team members to speak up when they notice problems. When this happens, checklists become catalysts for a more collaborative professional culture where expertise is enhanced rather than diminished by systematic approaches.

Chapter 5: Measuring Success: The Evidence of Improvement

The value of checklists ultimately rests on their demonstrable impact in real-world settings. Across diverse fields, properly designed and implemented checklists have produced remarkable improvements in performance and outcomes, often exceeding expectations. In 2009, the New England Journal of Medicine published the results of the WHO Safe Surgery Checklist pilot study conducted across eight diverse hospitals worldwide. The findings were stunning: major surgical complications decreased by 36 percent and deaths fell by 47 percent after checklist implementation. In absolute terms, the checklist prevented 150 complications and saved 27 lives among the 3,900 patients studied. These improvements occurred not just in resource-poor settings but in leading hospitals in high-income countries as well. The financial world has seen similar benefits. Mohnish Pabrai, managing partner of a $500 million investment fund, adopted a detailed investment checklist after studying Warren Buffett's approach. Despite his considerable experience, Pabrai recognized that his brain worked against him when evaluating potential investments, latching onto confirming evidence and dismissing warning signs. His checklist forced systematic consideration of crucial factors that emotion might otherwise override. After implementing his seventy-item checklist, Pabrai's results improved dramatically. During a single quarter of market turmoil in 2008, he was able to analyze over a hundred companies and add ten to his portfolio. One year later, these investments were up more than 160 percent on average, and he'd made no significant errors. Another investment manager, identified only as "Cook," found that using a checklist not only reduced errors but dramatically increased efficiency. Initially worried that the additional verification would slow decision-making, he discovered the opposite: "The process was more thorough but faster. It was one hit, and we could move on." His team could evaluate many more investments in less time because the checklist quickly identified which prospects deserved further consideration. Geoff Smart, a psychologist who studied venture capitalists, provided scientific validation of the checklist approach. He identified different decision-making styles among investors evaluating entrepreneurs and tracked their performance over time. Those taking a checklist-driven approach (whom he called "Airline Captains") had only a 10 percent likelihood of later firing senior management for incompetence, compared to at least 50 percent for those using more intuitive approaches. Their investment returns were correspondingly better—a median 80 percent return versus 35 percent or less for others. The evidence extends beyond finance and medicine. In construction, the disciplined use of checklists has reduced building failures to an astonishingly low rate—about twenty serious failures annually among nearly five million commercial buildings in the United States, an avoidable failure rate of less than 0.00002 percent. This safety record has been achieved even as buildings have become more complex and construction times have decreased by a third. Perhaps most convincingly, when professionals who initially resist checklists see these results, many become converts. At Johns Hopkins Hospital, after implementing central line infection checklists in ICUs, infection rates dropped from 11 percent to essentially zero over a 15-month period, preventing an estimated forty-three infections and eight deaths while saving about two million dollars. The cumulative evidence across fields demonstrates that checklists are not merely helpful but transformative when properly designed and implemented. They establish a higher standard of baseline performance, reduce variation in outcomes, improve teamwork, and free experts to focus on the truly challenging aspects of their work rather than worrying about routine details. Far from limiting professional judgment, well-designed checklists actually enhance it by ensuring that fundamental prerequisites for success are consistently in place.

Chapter 6: Beyond Medicine: Checklists in Every Field

The principles of effective checklist design and implementation extend far beyond surgery and aviation. They apply whenever humans face complexity, high stakes, and the possibility of failure due to overlooked steps or poor communication. The checklist mentality is transforming fields as diverse as investment management, disaster response, restaurant operations, and building construction. After Hurricane Katrina devastated New Orleans in 2005, traditional command-and-control approaches to disaster management failed catastrophically. Federal agencies refused to cede authority to state and local officials, who in turn wouldn't give decision-making power to those on the ground. Meanwhile, Wal-Mart took a fundamentally different approach. CEO Lee Scott issued a simple directive: "Make the best decision that you can with the information that's available to you at the time, and, above all, do the right thing." This distributed decision-making framework, supported by clear communication protocols, allowed Wal-Mart to respond with remarkable effectiveness. Store managers distributed emergency supplies on their own authority. They set up temporary pharmacies and created paper-slip credit systems for first responders. One assistant manager even bulldozed through her flooded store to salvage and distribute essential items. Within days, Wal-Mart had delivered 2,498 trailer loads of emergency supplies while government agencies were still arguing over jurisdictional issues. In the high-end restaurant world, chef Jody Adams of Boston's acclaimed Rialto relies on multiple checklists to maintain excellence night after night. These include not only detailed recipes—the most basic form of kitchen checklist—but also quality control checks before plates leave the kitchen, pre-service team briefings to discuss menu changes and special events, and systems for communicating issues between the dining room and kitchen. These protocols ensure that 150 guests each night receive consistently exceptional food despite the inherent variability and pressure of restaurant service. The construction industry has perhaps the most developed checklist culture outside aviation. Modern buildings involve sixteen different specialized trades working in precise sequence over months or years. Project managers like Finn O'Sullivan, who oversaw the construction of the Russia Wharf building in Boston, rely on two primary types of checklists: construction schedules that detail every building task in sequence, and "submittal schedules" that specify who needs to communicate with whom about what and by when. This communication checklist proved crucial when an unexpected problem emerged—upper floors appeared to be tilting inward due to settling of the concrete core. Rather than relying on one expert's judgment, the submittal schedule ensured that structural engineers, contractors, consultants, and owners all discussed the issue together and agreed on a solution. This systematic approach to both tasks and communication has made modern construction remarkably safe despite its complexity. Perhaps most surprisingly, checklists are proving valuable even in creative fields. David Lee Roth, the flamboyant former lead singer of Van Halen, famously included a clause in concert contracts requiring a bowl of M&Ms backstage with all brown candies removed. Far from being a rock star's capricious demand, this was actually a hidden checklist item. If Roth found brown M&Ms, he knew the venue hadn't read the contract carefully, signaling potential problems with the complex technical requirements for the band's elaborate stage show. In one case, this check revealed that the venue hadn't followed weight specifications, which could have caused the stage to collapse. The checklist mindset requires accepting that even highly skilled professionals have limits to memory, attention, and consistency under pressure. Rather than seeing checklists as constraints on autonomy or creativity, we should recognize them as tools that free our minds from routine concerns so we can focus on the challenging, nuanced aspects of our work that truly require human judgment. As aviation has discovered, discipline and creativity aren't opposing values—the former enables the latter by creating a foundation of reliability and teamwork upon which innovation can safely build.

Summary

At its core, this book challenges our fundamental understanding of what constitutes excellence in complex fields. The traditional model of the master expert—the virtuoso who performs flawlessly through sheer skill and concentration—no longer suffices in our increasingly complicated world. Instead, true excellence now requires both individual expertise and systematic approaches that compensate for our human limitations. As the evidence across diverse fields demonstrates, well-designed checklists serve as cognitive nets that catch our inevitable errors of memory, attention, and thoroughness. "We have most readily turned to the computer as our aid," the author observes. "But there is much that technology cannot do: deal with the unpredictable, manage uncertainty, construct a soaring building, perform a lifesaving operation." Checklists fill this gap, not by replacing human judgment but by enhancing it. They transform how teams function, distribute responsibility appropriately, and establish higher baseline standards of performance. The most profound insight may be that discipline and creativity aren't opposing values but complementary ones. By establishing discipline around routine aspects of complex work, checklists free our minds to focus on the challenging, unpredictable elements that truly require human ingenuity. The simplest action you can take today is to identify one complex, high-stakes activity in your work or life and create a basic checklist for it—not as a constraint but as a tool for liberation from the burden of preventable failure.

About Author

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Atul Gawande

Atul Atmaram Gawande is an American surgeon, writer, and public health researcher. He practices general and endocrine surgery at Brigham and Women's Hospital in Boston, Massachusetts. He is a professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health and the Samuel O. Thier Professor of Surgery at Harvard Medical School. In public health, he was the chairman of Ariadne Labs, a joint center for health systems innovation, and chairman of Lifebox, a nonprofit that works on reducing deaths in surgery globally. On June 20, 2018, Gawande was named the CEO of healthcare venture Haven, owned by Amazon, Berkshire Hathaway, and JP Morgan Chase and stepped down as CEO in May 2020, remaining as executive chairman while the organization sought a new CEO.He is the author of the books Complications: A Surgeon's Notes on an Imperfect Science; Better: A Surgeon's Notes on Performance; The Checklist Manifesto; and Being Mortal: Medicine and What Matters in the End.On November 9, 2020, he was named a member of President-elect Joe Biden's COVID-19 Advisory Board. On December 17, 2021, he was confirmed as the Assistant Administrator of the United States Agency for International Development, and he was sworn in on January 4, 2022.

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