Summary: The Checklist Manifesto by Atul Gawande

Book Summary

In "The Checklist Manifesto," Atul Gawande explores how the medical field can manage the increasing complexity of modern healthcare. Through a series of case studies, from a drowning victim's recovery to the successful emergency landing of US Airways Flight 1549, Gawande illustrates the power of checklists in catching preventable errors and fostering critical communication. He draws parallels to the construction industry, which has adapted to complexity by implementing systematic checks and balances, and argues that a similar approach could transform medical care.

Gawande and his team at the World Health Organization develop a safe surgery checklist, testing and refining it with the help of experts like Boeing's checklist specialist, Daniel Boorman. When implemented in eight hospitals worldwide, the checklist dramatically reduces surgical complications and deaths. However, many doctors resist adopting this tool, viewing it as a challenge to their expertise. Gawande explores this resistance to checklists across various fields, from investing to aviation, and ultimately argues for a new kind of heroism - one that recognizes the importance of teamwork, discipline, and adherence to protocols in achieving successful outcomes in complex, high-stakes situations.


  • A man with a stab wound in his abdomen arrives at the hospital on Halloween night
  • Initially, the injury seems minor, but the patient's condition suddenly deteriorates
  • The trauma team rushes him into surgery, where they discover a large amount of blood in his abdominal cavity

Chapter 2: The Problem Of Extreme Complexity

  • A three-year-old girl fell into an icy fishpond and was underwater for 30 minutes before being pulled out
  • She had no pulse and had ceased brain function, but emergency technicians continued CPR
  • Through a series of complex medical interventions over many days, including the use of a heart-lung bypass machine and an artificial lung system, her body temperature was raised and her organs began to recover
  • After being comatose for a week, she awoke and eventually made a full recovery after extensive therapy

Chapter 3: The Checklist

  • Harvard Vanguard, a community clinic in Boston's Kenmore Square, has grown to over twenty facilities with six hundred doctors and a thousand other health professionals covering fifty-nine specialties to keep up with the explosive growth in medical capabilities.
  • The average patient requires 178 individual actions per day in an ICU, and even with a 1% error rate, this amounts to an average of two errors per day with every patient.
  • Intensive care succeeds only when the odds of doing harm are held low enough for the odds of doing good to prevail, which is difficult given the extreme complexity.
  • Medicine has become increasingly complex, with ICUs, super-specialization, and teams of specialized professionals, but avoidable failures are still common.

Chapter 4: The End Of The Master Builder

  • The construction industry has evolved from the Master Builder model to a more specialized and coordinated approach due to the increasing complexity of modern buildings.
  • Architects, engineers, and builders have adapted to this reality by developing a system of checks and balances to ensure that every aspect of a building's design and construction is properly executed.
  • This is in contrast to the medical field, which still largely operates under the Master Physician model, leading to high rates of duplication, flaws, and lack of coordination in patient care.
  • The construction industry's approach to managing complexity and ensuring success could potentially serve as a model for the medical field to adapt to the realities of modern healthcare.

Chapter 5: The Idea

  • The construction industry uses checklists to manage complex projects and ensure critical steps are not missed
  • Checklists specify communication tasks, requiring experts to talk to each other at key points to discuss developments and agree on the way forward
  • Pushing the power of decision making to the periphery, giving people room to adapt based on their experience and expertise, is an effective strategy for dealing with complex, nonroutine problems
  • Building inspectors disperse power and responsibility, making sure builders have proper checks in place and having them sign affidavits attesting they have ensured the structure is up to code

Chapter 6: The First Try

Here is a summary of the chapter in 4 bullet points:

  • The World Health Organization convened experts to address the growing dangers of surgery worldwide, as the volume of operations has increased dramatically but so have complication rates.
  • Examples of successful public health interventions, like providing soap in Karachi slums, show the power of simple, measurable, transmissible solutions.
  • A surgical checklist was proposed as a potential "soap" for surgery - a simple tool to foster communication and catch preventable errors.
  • Early trials of surgical checklists at various hospitals showed promising results in catching common killers like infections, bleeding, unsafe anesthesia, and unexpected complications.

Chapter 7: The Checklist Factory

Here is a summary of the chapter in bullet points:

  • The author tried using a surgical checklist he helped develop at the WHO, but it failed miserably in practice because it was too long, unclear, and distracting.

  • The author consulted with Boeing's checklist expert, Daniel Boorman, to learn how to make an effective checklist.

  • Good checklists are precise, efficient, practical, and easy to use even in difficult situations. They don't spell out every single step but make priorities clear.

  • Effective checklists have clear pause points, use simple and exact wording, fit on one page, and focus on the most critical and commonly overlooked steps.

Chapter 8: The Test

  • The chapter describes the author's experience testing a surgical safety checklist in a Boeing 777 flight simulator with pilot Dan Boorman
  • After refining the checklist, the author and his team tested it in eight diverse hospitals around the world, from high-income to low-income settings
  • Before implementing the checklist, data collected from the hospitals showed surgical complication rates ranging from 6-21%, with substantial room for improvement everywhere
  • The final 19-item WHO safe surgery checklist was then introduced systematically in the pilot hospitals

Chapter 9: The Hero In The Age Of Checklists

Here is a summary of the chapter in 4 bullet points:

  • The WHO surgical safety checklist was successfully implemented in 8 hospitals around the world, reducing complications by 36% and deaths by 47%. However, many doctors resisted using it, seeing it as a challenge to their expertise and autonomy.

  • Some successful investors, like Mohnish Pabrai and an anonymous billionaire, have adopted checklists to avoid common investing mistakes and make better decisions. However, few other investors have followed their example despite the demonstrated benefits.

  • Research shows an "Airline Captain" checklist-driven approach is far more effective than intuitive decision making for venture capitalists evaluating entrepreneurs. Yet most VCs continue relying on gut instinct over systematic analysis.

  • When US Airways Flight 1549 successfully crash-landed in the Hudson River, the public focused on hailing the heroic pilot. But the outcome was equally due to teamwork, adherence to procedures, and use of checklists - an uncomfortable reality for our idea of heroism.

Chapter 10: The Save

  • The pilots, Sullenberger and Skiles, had never flown together before but adhered to strict discipline by running through checklists and briefing each other before the flight.
  • After hitting a flock of geese and losing engine power, Sullenberger took control of the plane while Skiles focused on restarting the engines and preparing for an emergency water landing.
  • The flight attendants followed protocols to ensure passenger safety during the evacuation, and the entire crew's teamwork and preparation allowed for a successful outcome.