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The Checklist Manifesto: How to Get Things Right

by Atul Gawande

Other authors: See the other authors section.

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3,0931233,643 (3.96)96
Reveals the surprising power of the ordinary checklist now being used in medicine, aviation, the armed services, homeland security, investment banking, skyscraper construction, and businesses of all kinds.

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» See also 96 mentions

Showing 1-5 of 120 (next | show all)
I love checklists, and it was really interesting to learn how the author helped create a checklist for surgery; the amount of work of details, testing, background learning, and the overall process make up this book. Most of his anecdotes make me hope to never need surgery ever, and all the flying accident (most not properly utilizing their checklists) overviews have me rather terrified of getting on a plane (& I’ve never had any flying fear in over forty years); likely the opposite of the predicted outcomes but oh well. ( )
  spinsterrevival | Sep 15, 2022 |
What if we had a relatively easy way to improve outcomes in a wide variety domains, but the technique made us feel a little less smart? In this book, Gawande argues that checklists are such a tool. Checklists are ubiquitous in commercial flight; they are starting to make inroads in medicine. They can decrease the incidence of the problems they are targeted to to degrees that would be considered huge successes for other interventions.

Yet when checklists are introduced into a new setting, there is often resistance. Gawande offers two reasons. First, we often feel that we don't need the checklists -- we're smart, and it's not like the information they're conveying is new. Second, good checklists are hard to design, and bad checklists waste time and increase frustration.

So why do checklists help? We're talking about smart people -- doctors, pilots, engineers. Don't they know this stuff already? Aren't their jobs too complicated to be reduced to a checklist? Gawande differentiates between three types of problems: simple problems, complicated problems, and complex problems. Simple problems are those where knowing the right techniques and following the recipe will give the right result. Complicated problems require coordination and planning. The parts may be individually simple or complex, but even if they're all simple, the sheer overhead of getting everything done and at the right time makes the problem challenging. Complex problems are those where every instance brings new challenges. The tools you use for simple and complicated problems may help, but fundamentally, complex problems require novel problem solving.

Checklists shine in the domain of the complicated, in the areas where each step is one where a trained practitioner would say "I know how to do that", but where, in the hectic conditions of the real world, it can be hard to actually remember to do each of the steps. Seeing improved outcomes when checklists are used does not mean that the practitioners are unskilled. Instead, checklists free up capacity for thinking about the complex aspects of a problem.

Freeing up capacity is not the only value checklists provide when dealing with complex problems. They can also be used to improve problem solving in a team setting. Checklists can provide communication checkpoints which can help with problem solving. E.g., by adding a step that gives everyone on the team a chance to express concerns they have about a procedure, you can reduce the incidence of conformity biases where people tend to feel less confident in their doubts if everyone else is confident.

The other common issue with checklists is that they can be bad. As Gawande puts it, "It is common to misconceive how checklists function in complex lines of work. They are not comprehensive how-to guides, whether for building a skyscraper or getting a plane out of trouble. They are quick and simple tools to buttress the skills of expert professionals."

What this means in practice is that checklists should be short, five to nine items is a good rule of thumb. They should be triggered by unambiguous pause points, e.g., just before making the first incision in an operation. The wording should be simple and exact; as implied above, a checklist should not be telling you how to do something, just that you should do it. Most importantly, a checklist should be tested under realistic conditions.

When is it worth doing all of this work to create a good checklist? Checklists should be targeted to situations where intervention can significantly change the odds of a good outcome. If the consequences of something being done wrong are not bad, cut it out of the list. If something is so ingrained that practitioners truly never forget it, cut it out of the list. But if there's something that's sometimes forgotten and makes a noticeable difference in aggregate, then that is a good candidate for a checklist.

In case you can't tell, I really liked this book and the message it conveys. This is not just because the specific ideas about checklists are useful. This book also expresses one of my core beliefs about process: a good process is one which allows people to feel like they are spending more time on what is most meaningful. A good process reduces the time spent on bureaucracy. A good process is the equivalent of automation for things that cannot yet be automated. Checklists are a good process. ( )
  eri_kars | Jul 10, 2022 |
Great stories about the effectiveness of checklists in aircraft cabins and in operating rooms, but it stops short on the analysis side. On the other hand, it led me to think more about why checklists work.

1. They shift the authority away from one "hero" (captain or surgeon) and to a neutral third party (the list), so the entire team can take responsibility. Gawande does mention this at the end of the book, but not in any depth.

2. If you've read "Thinking Fast and Slow", you'll guess that checklists slow us down and engage System 2 thinking. Unlike System 1 (intuition), System 2 (reasoning) uses negative evidence. That is critical for spotting errors and missed steps.

3. The book confuses two very different kinds of checklists, routine and exceptional. The routine checklists are used every single time, like preflight checks or anesthesia checks. The exceptional checklists are for things that might happen once in a professional's career, like losing the forward cargo door on an airliner. The first kind avoids emergencies and errors, the second mitigates them.

Finally, it sure would have been helpful to include some references on how to write checklists. ( )
  wunder | Feb 3, 2022 |
Very interesting. Not sure how to apply it in my work, but if I'm ever scheduled for surgery, I want a hospital which use them ( )
  smbass | Jan 30, 2022 |
Checklists are more important than one would think. When used right they can decentralize control, giving more autonomy to everyone in the organization, and improve the quality and efficiency of a process. This is this whole book boiled down to two sentences.

The book doesn't give more details or directions than the initial article it is based on. Instead, it presents a multitude of anecdotes and some statistics to prove the point. If you enjoy reading fascinating stories (mostly from the operating rooms) that build the tension and lead to interesting reveals - add 2 stars to my rating.

The stories are well written and each by itself is fine. However, as a collection, they become a bit repetitive and boring - each of them proves pretty much the same thing or has such a loose connection to the main subject that makes you wonder why it is included in this book. I was missing a stronger narrative that would connect them meaningfully. You can basically read chapters in random order and get the same value. ( )
  sperzdechly | Jun 26, 2021 |
Showing 1-5 of 120 (next | show all)
I already know that "The Checklist Manifesto" will be on my list of best books this year. Gawande writes with gusto, humor and clarity. He features his mistakes -- always a good sign in a reporter -- including the one that ends the book.
Read this book and you might find yourself making checklists for the most mundane tasks—and be better off for it.
But that narrative gift doesn't transfer automatically to accounts of in-flight safety checks and structural engineering near-misses. Gawande's style is always clear, with the crispy lilt that is a trademark of the New Yorker, where he is also a staff writer. But there's no escaping the fact that this is a book about, well, checklists. Hemingway would struggle to make it gripping. Gawande does well to pull off engaging.
added by stephmo | editThe Observer, Rafael Behr (Jan 24, 2010)
Gawande, a professor of surgery at Harvard Medical School and a staff writer at The New Yorker, makes the case that checklists can help us manage the extreme complexity of the modern world. In medicine, he writes, the problem is “making sure we apply the knowledge we have consistently and correctly.” Failure, he argues, results not so much from ignorance (not knowing enough about what works) as from ineptitude (not properly applying what we know works).
Dr. Gawande is right to note that checklists are indispensable in situations where a small mistake can lead to tragic consequences, as in surgery. But his call for a broad checklist regime would be counterproductive—fraught with all the dangers of bureaucracy and excessive law.

» Add other authors (4 possible)

Author nameRoleType of authorWork?Status
Atul Gawandeprimary authorall editionscalculated
Fyfe, LisaCover designersecondary authorsome editionsconfirmed
Levavi, Meryl SussmanDesignersecondary authorsome editionsconfirmed
Lloyd, John BedfordReadersecondary authorsome editionsconfirmed
Schloss, RoslynCopy editorsecondary authorsome editionsconfirmed
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I was chatting with a medical school friend of mine who is now a general surgeon in San Francisco.
Some time ago I read a case report in the Annals of Thoracic Surgery.
Faulty memory and distraction are a particular danger in what engineers call all-or-none processes: whether running to the store to buy ingredients for a cake, preparing an airplane for takeoff, or evaluating a sick person in the hospital, if you miss just one key thing, you might as well not have made the effort at all.
...the real lesson is that under conditions of true complexity—where knowledge required exceeds that of any individual and unpredictably reigns—efforts to dictate every step from the center will fail. People need room to act and adapt. Yet they cannot succeed as isolated individuals, either—that is anarchy. Instead, they require a seemingly contradictory mix of freedom and expectation—expectation to coordinate, for example, and also to measure progress toward common goals.
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Reveals the surprising power of the ordinary checklist now being used in medicine, aviation, the armed services, homeland security, investment banking, skyscraper construction, and businesses of all kinds.

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The modern world has given us stupendous know-how. Yet avoidable failures continue to plague us in health care, government, the law, the financial industry--in almost every realm of organized activity. And the reason is simple: the volume and complexity of knowledge today has exceeded our ability as individuals to properly deliver it to people--consistently, correctly, safely. We train longer, specialize more, use ever advancing technologies, and still we fail.
Now, acclaimed writer and surgeon Atul Gawande makes a compelling arguement that we can do better and finds a solution in the most humble of places: the lowly checklist. He explains how checklists have made possible some of the most difficult things people do--from flying airplanes to building skyscrapers of mind-boggling sophistication. And drawing on his own experience, he shows how applying this idea to the immensely various and complex world of surgery produced a ninety-second checklist that reduced deaths and complications by more than one-third in eight hospitals around the world--at virtually no cost and for almost any kind of operation.
In riveting stories, Gawande takes us from Austria, where an emergency checklist saved a drowning victim who had spent half an hour underwater, to Michigan, where a cleanliness checklist in intensive care units virtually eliminated a type of deadly hospital infection, and to the flight deck of a crashing plane. Along the way, he reveals what checklists can do, what they can't, and how they could bring about striking improvements in fields well beyond medicine, from homeland security to investment banking to professions and businesses of all kinds.
The Checklist Manifesto is a gripping exploration of the nature of complexity in our lives and essential reading for anyone working to get things right.
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