Checklist Manifesto by Atul Gawande

In 2006, Dr. Atul Gawande faced a seemingly impossible task. The World Health Organization (WHO) asked him to stem the rising number of deaths and complications resulting from surgeries world-wide.

The challenge was daunting. The hospitals he was tasked with improving couldn’t be more different. Some hospitals, like those in Toronto and Seattle, had cutting-edge technology and highly skilled teams, while others, in places like India and Jordan, were underfunded and lacked basic resources. Making matters worse, the WHO allocated virtually no budget for the initiative.

Despite these obstacles, Gawande and his team achieved incredible results. Within just three months, they reduced surgical deaths by 47% and major complications by 36%. If a new drug delivered similar results, it would dominate headlines and attract billions in funding. But Gawande and his team had not developed a miracle cure. They turned to something deceptively simple: the checklist.

Why Do We Fail?

To understand why Gawande’s approach succeeded, we first need to understand why we so often fail. Gawande argues that the central challenge of our time isn’t a lack of knowledge but our ability apply the knowledge we already have effectively. Despite knowing what to do, we often just don’t do it!

These types of failures can be infuriating. Consider a surgeon who forgets to wash his hands leading to the patient’s death. It’s easy to conclude that this was a moral failing of the surgeon. How could they not know better?

But Gawande argues it’s not that simple. The surgeon’s mind is preoccupied with hundreds of details relevant to the surgical strategy. He may even be facing time-pressure due to back-to-back surgeries. In this environment, getting every detail right is a herculean task.

Humans are fallible. When conditions are sufficiently complex, people make mistakes. This is true no matter how specialized the expert is and no matter how cutting-edge their tools are.

Avoidable failures are common and persistent, not to mention demoralizing and frustrating … and the reason is increasingly evident: The volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably.

A Better Way

To solve his problem, Gawande turned to industries where failure is not an option. He found inspiration in fields like aviation and high-rise construction.

Decades ago, flying was inherently risky. In the 1960s, the risk of a fatality in commercial air travel was 1 in 350,000 flights. By the 2010s, that number had improved to 1 in 7.9 million. As of 2022, it was an impressive 1 in 13.7 million. Despite a massive increase in air traffic, flying has become one of the safest modes of transportation.

Similarly, high-rise construction comes with significant risks. Engineers and builders must account for factors like load-bearing capacity, foundational stability, material fatigue, wind and aerodynamic forces, and seismic activity, among others. On top of that, these projects demand meticulous coordination between multiple teams, ensuring that every step is completed correctly. Yet, catastrophic failures in high-rise construction are remarkably rare.

Gawande discovered a common thread between these industries: both relied on checklists to minimize errors and ensure success. These weren’t simplistic “to-do” lists. They were structured protocols designed to tackle complexity and minimize mistakes. Rather than replacing expertise, the checklists complemented it. The result? Safer skies and sturdier buildings.

Inspired by these successes, Gawande and his team developed a surgical checklist to eliminate some of the most common and avoidable causes of death and disability. To their astonishment, it worked exceptionally well.

What Makes a Good Checklist?

Not all checklists are created equal. Poorly designed checklists can frustrate users or increase the likelihood of mistakes. Gawande highlights that thoughtful design is required to ensure that checklists help rather than hinder. Here are some key principles:

1. Keep it concise: A checklist should include no more than five to nine items. Overloading it with details makes it cumbersome and less likely to be used.
2. Focus on the essentials: Include only the most critical steps — those that are easy to miss but dangerous to overlook.
3. Use clear, simple language: Avoid jargon or overly technical terms. The goal is clarity, not to complicate.
4. Keep it visually clean: Fit the checklist on one page and avoid unnecessary visuals or distractions.
5. Define a pause point: Specify when the checklist should be used, such as “before starting surgery” or “if the airplane’s engine malfunctions.”
6. Choose the right format: There are two types of checklists. With “Do-Confirm” checklists, users complete tasks from memory, then review the checklist to confirm nothing was missed. With “Read-Do” checklists, users follow the checklist step-by-step, checking off each item as they go. The correct format will depend on the situation and the needs of the user.
7. Respect professional judgment: A checklist is not a substitute for expertise. It should encourage users to use their knowledge and judgment, not turn their brain off. For example, a pilots’ checklist for handling engine failure might include the step: “FLY THE AIRPLANE.”

Finally, every checklist must be tested in real-world conditions before full adoption. Initial drafts often fail to anticipate practical challenges and require refinement to be truly effective.

Good checklists … 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.

Overcoming Resistance to Checklists

Despite their effectiveness, checklists are not universally embraced. In fact, one of Gawande’s biggest challenges has been convincing hospitals to adopt them.

The resistance largely stems from how checklists challenge traditional notions of expertise. Many professionals, especially in fields like medicine, view them as unnecessary. After all, they’ve spent years training to master their craft—why would they need a “reminder” to do their job?

But this mindset misses the point. A checklist isn’t about replacing expertise; it’s about ensuring that expertise is applied consistently. Even the most skilled and experienced professionals are prone to errors, especially in high-pressure, complex environments.

Gawande argues that using a checklist requires a shift in values. It’s not about admitting failure but about embracing humility, discipline, and teamwork. It’s about recognizing that even the best among us benefit from systems that safeguard against inevitable lapses.

It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us—those we aspire to be—handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists. Maybe our idea of heroism needs updating.

Conclusion

Checklist Manifesto highlights a critical truth: the sheer volume and complexity of what we know has outpaced our ability to reliably apply it. Checklists offer a simple but powerful way to address this problem. They are a versatile tool for improving outcomes in any industry where precision and reliability are paramount — if we are willing to try.