The Checklist Manifesto
- A Review
Astha Gupta, M.Sc MHA PAHM

How to get thing Right
2
“1000 things can go wrong when you’ve got a patient with stab wounds”
Anaesthesiologist
used the wrong
concentration of
Potassium
No one remembered
to ask the ER team
what the weapon
was

How to get thing Right
3
“1000 things can go wrong when you’ve got a patient with stab wounds”
Two main reasons of failure
• Ignorance (Don’t know or know partially)
• Ineptitude (Know but fail to apply)
• Ignorance (1950s – heart patient put on bed rest for weeks in order to avoid strain to heart)
• Ineptitude (2006 - only 50% of hospitals had achieved door to balloon of less than 90 min)

Healthcare and its extreme complexity
4
• Complexity at two levels
• Diagnosis – ICD 10 14000 codes with open sections for further specificity. ICD-10
CM 68000
• Treatment – 24 hours period in an ICU requires 178 actions either by a nurse or a doctor
In Indian ICUs, the rate of vancomycin-resistant enterococcus (VRE), a dangerous
hospital infection, is five times the rate in the rest of the world
• What do you do when expertise is not enough?
• What do you do when super-specialists fail?

Learning from similarly complex sectors
5
Aeronuatics
• 1930s saw a major crash of Boeings newly commissioned aircraft
• Since then, the same fleet has completed 1.8 million flights without a single accident
But we are much more complex
• 41000 trauma patients in one state in US led upto 32261 unique combinations of
diagnosis
Think again
• Nursing uses a simple checklist which forms the basis of most complex diagnosis till date
• John hopkins – 5 point checklist for preparation towards inserting a central line reduced
ten day line infections from 11% to zero (2001)

6
Helps in memory recall
Organises tasks
Argument remains…Human body is far more complex!!!!

Learning from similarly complex sectors contd…
7
Construction
• Building is a like a human body
• Involves 16 separate specialities to come together
• Checklist for
• Every tasks under the plan
• Every foreseen adversary
• Communication and handling of the unforeseen
• Checklist work – 0.00002% rate of building failures

8
 Helps in memory recall
Organises tasks
Essential to complex environments
Helps in decision making

Learning from similarly complex sectors Contd…
9
Investment Funds
• Multiple levels of study
• Financials, culture, market outlook etc
• Growth prospects etc
• Multiple teams working together
• Sectors of investment can be as varied as healthcare at one and mining at other end

 Helps in memory recall
 Organises tasks
 Essential to complex environments
 Helps in decision making
10
 Inculcates discipline into the
process
 Process back in focus
“FLY THE PLANE”
 TEAM WORK

Why Us?
11
• Volumes of surgery exceeds the global totals of childbirth only with death rate 10-100 times
higher
• Surgeries leave 7 million people disabled and 1 million dead every year.
(A rate comparable with any public health concerns like malaria, tuberculosis etc)
• The unhealthy proposition of healthcare
“One in four surgeons believe juniors cannot question seniors”
64% 39% 28% 10%

The Worrisome Replacement
12
Healthcare
Skill
Trustworthiness Selflessness
Discipline

The Worrisome Replacement
13
Healthcare
Autonomy

The WHO Intervention
14
Checklist - The soap of surgical care
• Simple
• Transmissible
• Measurable
Counter the four roadblocks of Surgery
• Infection
• Bleeding
• Unsafe anaesthesia
• Unexpected - Communication
The pause points
• Before Anaesthesia Seven Checks
• After Anaesthesia Seven Checks
• Before Wheeling Out Five Checks

Good Checklist
15
• To the point
• Easy to use
• Does not spell out the steps
• Reminders of the most important and critical steps (Data suggested as most critical and
most frequently missed)
• Makes priorities clearer
• Has simple and exact wording
• Always in sentence case
• The pilot flying cannot start the checklist (he has a task at hand running through his
head)
• 60-90 seconds
Do Confirm
Read - Do

What checklists cannot do
16
Make people use them
Be applicable for all conditions
Decide inclusions/exclusions
Tide over hierarchical structures
Increase workload

Essential to Implementation
17
• Top down push for bottoms up implementation
• Customized to situation with common DNA
• Display positive effects with complying few
• Those essential to implementation need to be pulled in via management
• Can lead to change in established practices

Way Ahead
18
Specialised Checklist
• Hip Replacement
Disaster/Emergency Control
• Like in Aviation
Team work and discipline

About the Author
19
• Atul Gawande is an Indian American surgeon and journalist.
• He is widely known as an expert on reducing error, improving safety, and increasing efficiency
in modern surgery.
• General and endocrine surgeon at Brigham and Women's Hospital in Boston, Massachusetts
• Associate director of BWH Center for Surgery and Public Health.
• Associate professor at Harvard School of Public Health
• Associate professor of surgery at Harvard Medical School.
• He has written extensively on medicine and public health