Nate’s Notes 22: The Power of Checklists

Four months after graduating from business school, I got my first real job, working in hospital operating rooms as a medical device rep. Although I had never taken a class in human anatomy, I was suddenly in a world of scalpels, bone saws, titanium plates, and cauterized flesh. It was my job to ensure that the doctors had the equipment necessary to conduct hip and knee replacements, and if there was ever a question about how to use an instrument, or a question about the specs of the implants, I was the surgeons’ resource.

Watching surgeons cut out arthritic joints, and then hammer, screw, and glue in artificial joints —not to mention all the other sights, sounds, and smells—was a world that I never expected to enter. But I also got insight into a simple practice that was seemingly so unimportant, so mundane, that I had always underestimated it. And that was the practice of using checklists.

When I first started working in the OR, I was surprised to see the nurses ask the doctors such basic questions: Have you washed your hands. Yes. Is this patient John Smith. Yes. Are we operating on the left knee. Yes. Are we performing a total knee replacement? Yes. Item after monotonous item was read off and verified, both at the beginning of surgery, during surgery, and even at the end of surgery. (We used 9 sponges. Are all accounted for…1,2,3,4,5,6,7,8,9.yes.)

Checklists weren’t always used in hospitals, and millions of patients paid the ultimate price for it. Perhaps the most well known use of a checklist resulted from the work of the Hungarian Physician, Ignaz Semmelweis. In 1847, decades before germ theory was formalized, Semmelweis noticed that women who delivered babies in the hospital were dying at significantly higher rates than women who delivered babies at home. Semmelweis concluded that the deaths were caused by physicians working on multiple patients without washing their hands in between, thus spreading infection. By introducing hand washing, mortality rates fell from about 10% to about 1.5%.

However, a hundred years after Semmelweis’ discovery, American doctors were still not following proper procedures. Hundreds of thousands of patients were dying in surgery each year, with at least 1/2 of the deaths caused by avoidable human error. For example, the CDC published their findings that adherence to hand washing guidelines averaged just 40%. So how did hospitals respond? By posting a 1 item checklist outside the entrance of each hospital room that said, “Wash Your Hands.”

Checklists have since evolved in hospitals, and saved millions of lives as a result. For example, one of the most commonly used checklists consists of just four items: blood pressure, body temperature, pulse, and respiratory rate. This 4-item checklist, known as vital signs, is the most basic indicator of overall patient health.

Checklists are also used in surgical procedures. For example, putting in a central line is a straightforward, routine process, consisting of several steps, such as wearing proper clothing, washing hands with soap, cleaning the patients’ skin, and putting sterile drapes on the patient. Central lines deliver medicine and treatment directly to the heart, and thus adherence to each step is crucial in preventing infection.

However, at John’s Hopkins hospital, one of the premier health care facilities in the world, doctors were skipping steps nearly 1/3 of the time. It wasn’t that doctors didn’t think the steps were important…they were either in a rush, or simply forgetting.

To get 100% compliance from all doctors, researchers decided they would implement the use of a checklist. Doctors and nurses had to verbally confirm that each step on the checklist was completed before moving to the next step.

The checklist was implemented in 108 hospitals throughout Michigan, and in just 2 years infection rates decreased by 66% saving more than 1500 lives and $175 million in costs. Checklists were then adopted for hundreds of other tasks completed in the ICU on a given day, and thus, the number of lives that checklists now save is hard to appreciate. That said, some doctors still resist using checklists. After all, doctors are experienced, intelligent professionals, and using a checklist feels childish. But if you ask doctors if they would want a surgeon to use a checklist if operating on them, the answer is almost always yes.

Although I first noticed the use of checklists in the operating room, it wasn’t until I read Atul Gwandes book, titled the Checklist Manifesto, that I fully appreciated just how powerful checklists are. Gwande demonstrates the power of checklists not only in hospital settings, but also in other high stakes fields such as construction and aviation.

For example, in the United States we have millions of commercial buildings and more than 100 million residential homes. Yet how often do these buildings collapse due to avoidable error? Almost never…just 1 in 50,000 structures partially collapse due to human error. Even experienced builders don’t build homes from memory. A builder who has built hundreds, or even thousands of buildings still consults architectural plans that guide them through the process step by step. These plans are nothing more than checklists.

Or think of the airline industry. The odds of dying on an airplane is approximately 1 in 30 million. This stellar safety record is due, in large part, to the fact that airline mechanics and pilots rely on checklists. Pilots and mechanics with thousands of hours of experience still consult a checklist before making any major decisions.

Each of these industries has internalized an obvious truth, but one that is easy to overlook: Humans make lots of silly mistakes. We forget small details, we skip simple steps, and we have unreliable memories. Checklists help us catch our flaws…help us avoid the avoidable errors. Checklists are so easy to underestimate in large part because they are so simple. But the use of checklists can have profound impacts. Consulting checklists can mean the difference between life and death.

Obviously not every task in life requires a checklist. But the number of tasks where checklists should be used, by both novices and experts, is likely under appreciated. For example, while in school, use a checklist for all of your assignments and due dates. In your job, use a checklist for all of your important responsibilities and tasks. When you pack for vacation or go to the grocery store, use a checklist to make sure you don’t forget anything.

And perhaps more importantly use checklists in your personal life to make sure you reach your daily physical, mental, spiritual, and emotional goals. If you’re not using checklists, you’re probably not reaching your potential. The discipline to use and follow checklists may be the most important skill you ever develop.

It’s a simple idea. Please take it seriously.