Checklists: Why doesn’t everyone do it?

Some years ago, just before going into surgery, a loved one asked me to place a sticky note on one of her knees so that the surgeon wouldn’t mistakenly operate on the other. I thought it was a bit too aggressive and didn’t. But I made sure to remind the surgeon and the lead nurse in person, looking into their eyes, that it was the right knee, not the left one, in half-jest.


Apparently, we weren’t the only ones who should worry about this, as The Independent reports:

Surgeons in England and Wales will be ordered today to carry out a safety checklist before every operation they perform, after a study showed it cut surgical deaths and complications by a third.

Described as the biggest clinical innovation in 30 years, the checklist is based on a set of seemingly banal questions but is set to become as essential to daily medicine as the stethoscope. In Britain alone, the new procedure could save hundreds of lives a year and 80,000 complications.

Estimated operations around the world approaching 250,000 per year, the stakes are enormous:

Atul Gawande, an American surgeon and associate professor at the Harvard School of Public Health, who led the study, said work was under way on further checklists for maternity and childbirth (to be published this year), heart disease, pneumonia, HIV and mental health. “It is one of those simple, unbelievably powerful ideas that will have an impact across medicine. Surgeons had assumed that doing well for patients was mostly about their skill. But there is now too much technology and too many patients for one person to deal with.”

He added: “When I talk to clinicians, they say: ‘we already do this stuff.’ The answer is: we are good at doing it most of the time, but we are not good at doing it all the time. We found some members of the team felt they were such low agents, they only felt responsible for their corner. Being allowed to say who they were [one item on the checklist] and hear the surgeon say what he expected made them feel part of the team. When you are not given a voice you turn your brain off.”

Over the years, I have trained and mentored many designers, developers and analysts. I’ve found it quite difficult to get them to first create and then methodically follow checklists. Some of the most egregious and preventable mistakes often result from failing to follow just a few checkable items. Not all mistakes harm people but end up wasting a lot of time, like when a developer was nearly in tears after spending an entire afternoon trying to debug an XML-to-PDF-to-print utility. The printer wasn’t on.

I have nearly given up on homo sapiens reliably executing checklists. So my design and management practice has moved on to analytics/rules driven system design where such failure is assumed and thus automated out of existence, without hopefully making the system too brittle. It’s of course harder to design that way up-front, but the pay-off is undeniably worth it, time after time .

5 thoughts on “Checklists: Why doesn’t everyone do it?

  1. Richard: “emergency checklist requirements cited by Malcolm Gladwell in Blink”

    Don’t know, but checklists have been a part of “best practice” approaches in many different disciplines going back decades. Some instantiations have been codified into “hardware,” as in double-key activation procedures in banking, military and industrial operations, where sequential attention of multiple people are synchronized by force.

  2. Incidentally:

    “The US financial advisor who attempted to fake his own death in a light aircraft crash will certainly not be elevated to the pantheon of criminal masterminds, after police yesterday revealed he’d left a bullet-point list of his fake distress call in the plane before bailing out.”

    Police found

    “evidence including a book of campsites in America missing its pages on Alabama and Florida, and a bullet-point list scribbled on the back of a book that read: ‘cracked windshield, window imploded, bleeding profusely’.”

    Need I say more on checking checklists! :-)

  3. Brandan Lennox: “A computer executing a faulty checklist…”

    Fair warning. That’s why I emphasized “without hopefully making the system too brittle”.

    The difference, however, is that in complex systems I design, the computer with a rules engine can consider a range of I/O, criteria, rules, datasets, analytics and workflow far, far larger than any homo sapien can in real time.

    A moderately complex decision tree can produce a permutation of several million decision points. Even if you eliminate all redundancies, there would remain literally thousands of inter-related decision points to cut through to arrive at a final action. Computers can do this better than homo sapiens. There are things like pattern recognition that humans are better at in certain situations, but I fear not for too long.

    So, yes, there’s no fool-proof “checklist processor,” machine or human. But while homo sapiens often forget, machines don’t. I suppose our last defense against the machine is “creativity.” :-)

  4. At my previous job, (nearly) every task for every person had an associated checklist. Whoever completed the checklist was required to initial it. Some items on the list also had buddy checks. Since most of the tasks were very routine, this system worked well. There were only a few drawbacks.

    The first is dependencies. “If this task is of this certain type, perform these subtasks. Otherwise, don’t.” That’s hard to communicate in a static, printed checklist, and you end up with lots of crossed-out items and un-filled-out fields. You can’t glance at the list and quickly see what’s left to do. Not a huge deal, but a shortcoming nonetheless.

    The second is that, since the checklist generally prevented people from making minor blunders, the mistakes that *did* occur were major. Perhaps this is more of a morale issue, because when people screwed up, it was a big deal.

    The biggest problem, though, was that people forgot how to think on their own. As long as the checklist was complete, we assumed the task would succeed. But every project was unique, the parameterizations weren’t perfect, and the machines themselves were highly susceptible to environmental changes that couldn’t always be squeezed into a single checklist item.

    I don’t think you can blame homo sapiens for not being able to execute checklists. A computer executing a faulty checklist (i.e., a program) will be just as likely to fail as a human (if not moreso, since most computers can’t “think outside the box” of instructions they’ve been given). Our problem is coming up with a perfect checklist. Or more likely, balancing between crossing items off a list and actually analyzing the situation.

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