Book Summary

The checklist manifesto By ATUL GAWANDE

As the saying goes, “to err is human….” However, some errors are certainly avoidable. Author Atul Gawande like many of us hates making these avoidable errors. His errors don’t just hurt his reputation. Instead, they can even end people’s lives. Gawande is a surgeon and if he makes small oversights like forgetting to wash his hands before surgery or forgetting to make sure that there’s enough reserve blood on hand this would put his patients’ life in jeopardy. Despite the advancements in surgery and the number of surgeries performed every year, more than a hundred and fifty thousand Americans die each year during surgery.

Gawande says that research consistently shows that half of all deaths and major complications during surgery are due to avoidable human error. These errors include not washing your hands or failing to confirm that there’s enough reserve blood on hand before surgery. Having so many lives lost to avoidable errors in the operating room is just unacceptable, so Gawande set out to find a solution.

He searched for other high-stakes professions that have severely minimized human error and have maintained a reputation for excellence despite operating in a risky and complex environment. On his quest he interviewed leaders from the construction and aviation industries; two industries rich with complexity in danger but two industries where catastrophic events rarely occur.

The construction industry has a building failure rate of only 0.00002 %. That means only one in every 50,000 structures partially or entirely collapses due to avoidable human error and despite how complex an aircraft is, the odds of being killed on a single airline flight are 1 in 29.4 million. Both industries have an excellent track record because they’ve developed a habit of consulting a checklist before completing important tasks and making critical decisions.

The construction industry uses checklist throughout the building process to ensure that work meets building standards. A structural engineer who has built hundreds of similar buildings and is considered a master of their craft still consults a checklist every time he lays a foundation or starts construction on a new floor of a building. Despite hundreds of flights and thousands of hours of training, a veteran pilot still consults a checklist before making any major decision.

For example, shortly after captain sully left from Guardia airport on the morning of January 15th 2009, he struck a flock of geese and lost both engines on his aircraft. Despite the intense panic and the pressure to make a quick decision, he and his copilot consulted a checklist before taking their next action. After going through a checklist to accurately assess the situation, he could confidently make the decision to land the plane in the Hudson River and save everyone on board.

The aviation and construction industries understand an uncomfortable truth. We humans are flawed decision makers and have unreliable memories. We may know what’s best and we may have vast experience to back us up but we will always forget small details and miss important steps. Atul Gawande says, “For generations after the 1st aviation checklist went into use, a lesson is emerging. Checklists seem able to defend anyone even the experienced against failure and many more tasks than we realized. They provide a kind of cognitive net. They catch mental flaws inherit in all of us: flaws of memory and attention and thoroughness.

Without checklists, builders and pilots would not have the excellent track record they have and the general public wouldn’t trust them. Their discipline to consult checklists no matter how familiar they are with their jobs is what makes them responsible professionals.”

Gawande took his findings from both industries and started making checklists for surgeons in the operating room. After three months of the surgeons and nurses using a checklist for every operation, major complications due to avoidable human error dropped by 36 percent. Deaths fell by 47 percent. How did this happen?

Well before each surgery, a nurse would read off each item of a checklist out loud and then use a pen to check off each item manually. The items on the list were as simple as “verify that the correct patients on the table.” The doctors and nurses never skipped an item and they delayed surgery until every item on the list was verified. Like most people the doctors put up a lot of resistance to using a checklist. They were sophisticated professionals after all. But once they started seeing the affected had and the disasters it prevented, they learned to embrace checklists.

It was humbling for doctors to realize that despite their extensive training, a large number of surgeries performed and relatively high iqs, they were still prone to forgetting simple things and making common oversights.

Now you may not be saving lives but you can develop an excellent track record of producing high-quality work by developing the discipline to consult a checklist before issuing important projects or making critical decisions. However, if your checklists suck, you’ll resist using them and you’ll continue to release work with errors and people will doubt the professionalism of your work.

To find out how to make awesome and reliable checklists, let’s turn to a checklist expert; Boeing engineer Daniel Borman, a man who makes checklists for a living. Dan identifies four components of every useful checklist.

Component 1: a useful checklist has a clear pause point; a particular point in time where you know to pause and complete the checklist. For example, i use a checklist when publishing a blog post on my website to verify that the posts content is grammatically correct and that the links are working. The pause point is just before i hit the publish button on a new post.

Component 2: a useful checklist is speedy. Daniel Borman recommends that each checklist be less than 60 seconds to complete. Any longer and you’ll resist doing it or you’ll start taking shortcuts. To make a checklist speedy, you should aim for five to nine killer items. A killer item is an item that if missed would give the impression of poor quality or would have a negative impact on another person’s live component.

Component 3: a useful checklist is a supplement to existing knowledge and expertise. A checklist should not allow you to turn your brain off and execute a task like a robot. Each item should be a short and concise reminder; a way of triggering a familiar routine.

Component 4: a useful checklist is field tested and continually updated. A checklist should be practical and based on actual experiences. If it’s not you won’t trust it.

An ideal checklist is made up of past failures and lessons learned so if you develop the discipline to consult a well-made checklist, one that has these four components before hitting send on an important project or making an important decision, you can reduce your anxiety and cultivate the reputation for releasing high quality work. The discipline to use the checklist signals the difference between being an amateur and a professional.  

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