The Checklist Manifesto: How to Get Things Right

Nursing Book Club

The Checklist Manifesto: How to Get Things Right

A checklist helps reduce panic in unfamiliar situations

By Atul Gawande (Picador, 2009)
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Reviewed By Christine Contillo, RN, BSN

Right after one of the other nurses on my unit returned from the vaccine refrigerator with the wrong vial in her hand, I decided to read The Checklist Manifesto by Atul Gawande. He is the author of two other best-selling books, a practicing surgeon, associate professor at Harvard University and winner of a MacArthur genius award. Certainly if there’s any way to improve upon current medical practice, he has already taken a long hard look at it.

Gawande rightly points out that the way medicine is practiced has become technologically complex. At the same time, the average age of working nurses is now well into middle age. It’s clear that more and more is required of us at a time when our lives are probably least able to cope with longer shifts or learning difficult computer programs.

The author’s solution is a simple checklist, much like that used by the airline industry. A checklist helps reduce panic in unfamiliar situations and allows everyone involved to know exactly what is expected of them. An example of successful use of a checklist goes back to 1989 when a United Airlines flight suffered an explosion caused by an unlatched cargo door. The sudden decompression resulted in the loss of five rows of business class seats and nine passengers. In the midst of the confusion that followed, with debris flying and passengers screaming, the cockpit recorder shows the captain calmly asks for the checklist. Reviewing the checklist with his flight engineer during what was a totally unfamiliar event helped him regain control of the plane and land safely.

How does this relate to improving surgery? In a number of ways. It places someone (often a nurse) in charge of ensuring that the steps are always taken, with strict consequences if they are not. Examples might be improving handwashing compliance, having bloodwork completed before surgery, having blood on hand during surgery, or even having everyone on the team identify themselves to the patient to improve group cohesiveness.

This concept of completing a checklist was revolutionary in the world of medicine, where practitioners are known for having their own style and being reluctant to be coerced. A checklist therefore manages this kind of behavior in a non-subjective way. A simple surgical checklist has now been developed by the World Health Organization and has made more progress toward improving healthcare in developing nations than most of the protocols developed during the previous 30 years.

In my case, our director came up with a simple tear-off sheet listing all the vaccines we store. Since most patients receive more than one vaccine at a time — sometimes as many as 8 — we no longer have to walk down the hall to the vaccine refrigerator with a scribbled post-it, or trust our aging memories. The use of a checklist could be expanded to improve any aspect of care that might be impacted by panic (such as the steps to take during a code), or by inattention due to the routine nature of a procedure (such as an administrative referral to a specialist).

Gawande never fails to be informative and readable. Most of the book demonstrates how the concept of checklists was developed and implemented with enough detail to hold your interest. I never tire of his essays on medicine and always feel inspired to improve my own nursing practice.


Christine Contillo, RN, BSN is a public health nurse who suggests joining a book club as a reason to put down trashy magazines and look smart on the subway.

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