Checklist Manifesto Quotes

Man is fallible, but maybe men are less so.

What is needed, however, isn't just that people working together be nice to each other. It is discipline. Discipline is hard--harder than trustworthiness and skill and perhaps even than selflessness. We are by nature flawed and inconstant creatures. We can't even keep from snacking between meals. We are not built for discipline. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.

the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably.

Good checklists, on the other hand are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything--a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps--the ones that even the highly skilled professional using them could miss. Good checklists are, above all, practical.

One essential characteristic of modern life is that we all depend on systems—on assemblages of people or technologies or both—and among our most profound difficulties is making them work.

sometime over the last several decades—and it is only over the last several decades—science has filled in enough knowledge to make ineptitude as much our struggle as ignorance.

under conditions of complexity, not only are checklists a help, they are required for success.

We don’t like checklists. They can be painstaking. They’re not much fun. But I don’t think the issue here is mere laziness. There’s something deeper, more visceral going on when people walk away not only from saving lives but from making money. It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us—those we aspire to be—handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists. Maybe our idea of heroism needs updating.

And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.

You must decide whether you want a DO-CONFIRM checklist or a READ-DO checklist. With a DO-CONFIRM checklist, he said, team members perform their jobs from memory and experience, often separately. But then they stop. They pause to run the checklist and confirm that everything that was supposed to be done was done. With a READ-DO checklist, on the other hand, people carry out the tasks as they check them off—it’s more like a recipe. So for any new checklist created from scratch, you have to pick the type that makes the most sense for the situation.

checklists seem able to defend anyone, even the experienced, against failure in many more tasks than we realized.

There are good checklists and bad, Boorman explained. Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat the people using the tools as dumb and try to spell out every single step. They turn people’s brains off rather than turn them on. Good checklists, on the other hand, are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything—a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps—the ones that even the highly skilled professionals using them could miss. Good checklists are, above all, practical. The power of

Instead they choose to accept their fallibilities. They recognised the simplicity and power of using a checklist.

Atul Gawande, The Checklist Manifesto

Atul Gawande’s recent A Checklist Manifesto

The power of checklists is limited, Boorman emphasized. They can help experts remember how to manage a complex process or configure a complex machine. They can make priorities clearer and prompt people to function better as a team. By themselves, however, checklists cannot make anyone follow them. I

We are all plagued by failures - by missed subtleties, overlooked knowledge, and outright errors. For the most part, we have imagined that little can be done beyond working harder and harder to catch the problems clean up after them. We are not in the habit of thinking the way the army pilots did as they looked upon their shiny new Model 299 bomber — a machine so complex no one was sure human beings could try it.

So Pabrai added the following checkpoint to his list: when analysing a company, stop and confirm that you’ve asked yourself whether the revenues might be overstated or understated due to boom or bust conditions.

It is common to misconceive how checklists function in complex lines of work. They are not comprehensive how-to guides, whether for building a skyscraper or getting a plane out of trouble. They are quick and simple tools aimed to buttress the skills of expert professionals. And by remaining swift and usable and resolutely modest, they are saving thousands upon thousands of lives. *

The philosophy is that you push the power of decision making out to the periphery and away from the center. You give people the room to adapt, based on their experience and expertise. All you ask is that they talk to one another and take responsibility. That is what works. The

Much of our work today has entered its own B-17 phase. Substantial parts of what software designers, financial managers, firefighters, police officers, lawyers, and most certainly clinicians do are now too complex for them to carry out reliably from memory alone. Multiple fields, in other words, have become too much airplane for one person to fly. Yet it is far from obvious that something as simple as a checklist could be of substantial help.

checklists seem able to defend anyone, even the experienced, against failure in many more tasks than we realized. They provide a kind of cognitive net. They catch mental flaws inherent in all of us—flaws of memory and attention and thoroughness. And because they do, they raise wide, unexpected possibilities. But

I tried not to seem like a kid who’d just been offered a chance to go up to the front of the plane and see the cockpit. Sure, I said. That sounds neat.

The biggest cause of serious error in this business is a failure of communication,

We are besieged by simple problems.... Checklists can provide protection

You would think that this would be whether the entrepreneur’s idea is actually a good one. But finding a good idea is apparently not all that hard. Finding an entrepreneur who can execute a good idea is a different matter entirely. One needs a person who can take an idea from proposal to reality, work the long hours, build a team, handle the pressures and setbacks, manage technical and people problems alike, and stick with the effort for years on end without getting distracted or going insane. Such people are rare and extremely hard to spot.

the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us. That

No, the more familiar and widely dangerous issue is a kind of silent disengagement, the consequence of specialized technicians sticking narrowly to their domains. “That’s not my problem” is possibly the worst thing people can think, whether they are starting an operation, taxiing an airplane full of passengers down a runway, or building a thousand-foot-tall skyscraper.

You want people to make sure to get the stupid stuff right. Yet you also want to leave room for craft and judgment and the ability to respond to unexpected difficulties that arise along the way.

Here, then, is our situation at the start of the twenty-first century: We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And, with it, they have indeed accomplished extraordinary things. Nonetheless, that know-how is often unmanageable. Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields—from medicine to finance, business to government. And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us. That

Listening to the radio, I heard the story behind rocker David Lee Roth’s notorious insistence that Van Halen’s contracts with concert promoters contain a clause specifying that a bowl of M&M’s has to be provided backstage, but with every single brown candy removed, upon pain of forfeiture of the show, with full compensation to the band. And at least once, Van Halen followed through, peremptorily canceling a show in Colorado when Roth found some brown M&M’s in his dressing room. This turned out to be, however, not another example of the insane demands of power-mad celebrities but an ingenious ruse. As Roth explained in his memoir, Crazy from the Heat, “Van Halen was the first band to take huge productions into tertiary, third-level markets. We’d pull up with nine eighteen-wheeler trucks, full of gear, where the standard was three trucks, max. And there were many, many technical errors—whether it was the girders couldn’t support the weight, or the flooring would sink in, or the doors weren’t big enough to move the gear through. The contract rider read like a version of the Chinese Yellow Pages because there was so much equipment, and so many human beings to make it function.” So just as a little test, buried somewhere in the middle of the rider, would be article 126, the no-brown-M&M’s clause. “When I would walk backstage, if I saw a brown M&M in that bowl,” he wrote, “well, we’d line-check the entire production. Guaranteed you’re going to arrive at a technical error.… Guaranteed you’d run into a problem.” These weren’t trifles, the radio story pointed out. The mistakes could be life-threatening. In Colorado, the band found the local promoters had failed to read the weight requirements and the staging would have fallen through the arena floor.

Self-Management If you can read just one book on motivation—yours and others: Dan Pink, Drive If you can read just one book on building new habits: Charles Duhigg, The Power of Habit If you can read just one book on harnessing neuroscience for personal change: Dan Siegel, Mindsight If you can read just one book on deep personal change: Lisa Lahey and Bob Kegan, Immunity to Change If you can read just one book on resilience: Seth Godin, The Dip Organizational Change If you can read just one book on how organizational change really works: Chip and Dan Heath, Switch If you can read just two books on understanding that change is a complex system: Frederic Laloux, Reinventing Organizations Dan Pontefract, Flat Army Hear interviews with FREDERIC LALOUX, DAN PONTEFRACT, and JERRY STERNIN at the Great Work Podcast. If you can read just one book on using structure to change behaviours: Atul Gawande, The Checklist Manifesto If you can read just one book on how to amplify the good: Richard Pascale, Jerry Sternin and Monique Sternin, The Power of Positive Deviance If you can read just one book on increasing your impact within organizations: Peter Block, Flawless Consulting Other Cool Stuff If you can read just one book on being strategic: Roger Martin and A.G. Lafley, Playing to Win If you can read just one book on scaling up your impact: Bob Sutton and Huggy Rao, Scaling Up Excellence If you can read just one book on being more helpful: Edgar Schein, Helping Hear interviews with ROGER MARTIN, BOB SUTTON, and WARREN BERGER at the Great Work Podcast. If you can read just two books on the great questions: Warren Berger, A More Beautiful Question Dorothy Strachan, Making Questions Work If you can read just one book on creating learning that sticks: Peter Brown, Henry Roediger and Mark McDaniel, Make It Stick If you can read just one book on why you should appreciate and marvel at every day, every moment: Bill Bryson, A Short History of Nearly Everything If you can read just one book that saves lives while increasing impact: Michael Bungay Stanier, ed., End Malaria (All money goes to Malaria No More; about $400,000 has been raised so far.) IF THERE ARE NO STUPID QUESTIONS, THEN WHAT KIND OF QUESTIONS DO STUPID PEOPLE ASK?

Good checklists, on the other hand, are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything—a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps—the ones that even the highly skilled professionals using them could miss. Good checklists are, above all, practical.

He also found he made mistakes in handling complexity. A good decision requires looking at so many different features of companies in so many ways that, even without the cocaine brain, he was missing obvious patterns. His mental checklist wasn’t good enough. “I am not Warren,” he said. “I don’t have a 300 IQ.” He needed an approach that could work for someone with an ordinary IQ. So he devised a written checklist.

The investigators at Johns Hopkins and elsewhere had also observed that when nurses were given a chance to say their names and mention concerns at the beginning of a case, they were more likely to note problems and offer solutions. The researchers called it an “activation phenomenon.” Giving people a chance to say something at the start seemed to activate their sense of participation and responsibility and their willingness to speak up. These

the real lesson is that under conditions of true complexity—where the knowledge required exceeds that of any individual and unpredictability reigns—efforts to dictate every step from the center will fail. People need room to act and adapt. Yet they cannot succeed as isolated individuals, either—that is anarchy. Instead, they require a seemingly contradictory mix of freedom and expectation—expectation to coordinate, for example, and also to measure progress toward common goals. This

Expertise is the mantra of modern medicine. In the early twentieth century, you needed only a high school diploma and a one-year medical degree to practice medicine. By the century’s end, all doctors had to have a college degree, a four-year medical degree, and an additional three to seven years of residency training in an individual field of practice—pediatrics, surgery, neurology, or the like. In recent years, though, even this level of preparation has not been enough for the new complexity of medicine.

The Checklist Manifesto by Atul Gawande

But it’s not only the breadth and quantity of knowledge that has made medicine complicated. It is also the execution—the practical matter of what knowledge requires clinicians to do.

It’s an opaque term, intensive care. Specialists in the field prefer to call what they do critical care, but that still doesn’t exactly clarify matters.

The philosophy is that you push the power of decision making out to the periphery and away from the center. You give people the room to adapt, based on their experience and expertise. All you ask is that they talk to one another and take responsibility. That is what works.

In the face of the unknown—the always nagging uncertainty about whether, under complex circumstances, things will really be okay—

Of all organizations, it was oddly enough Wal-Mart that best recognized the complex nature of the circumstances, according to a case study from Harvard’s Kennedy School of Government. Briefed on what was developing, the giant discount retailer’s chief executive officer, Lee Scott, issued a simple edict. “This company will respond to the level of this disaster,” he was remembered to have said in a meeting with his upper management. “A lot of you are going to have to make decisions above your level. Make the best decision that you can with the information that’s available to you at the time, and, above all, do the right thing.” As one of the officers at the meeting later recalled, “That was it.” The edict was passed down to store managers and set the tone for how people were expected to react. On

We know the patterns. We see the costs. It’s time to try something else. Try a checklist.

Faulty memory and distraction are a particular danger in what engineers call all-or-none processes: whether running to the store to buy ingredients for a cake, preparing an airplane for takeoff, or evaluating a sick person in the hospital, if you miss just one key thing, you might as well not have made the effort at all. A

Checklists seem to provide protection against such failures. They remind us of the minimum necessary steps and make them explicit. They not only offer the possibility of verification but also instill a kind of discipline of higher performance.

We are not omniscient or all-powerful. Even enhanced by technology, our physical and mental powers are limited.

You must decide whether you want a DO-CONFIRM checklist or a READ-DO checklist.

You must decide whether you want a DO-CONFIRM checklist or a READ-DO checklist. With a DO-CONFIRM checklist, he said, team members perform their jobs from memory and experience, often separately. But then they stop. They pause to run the checklist and confirm that everything that was supposed to be done was done. With a READ-DO checklist, on the other hand, people carry out the tasks as they check them off—it’s more like a recipe. So for any new checklist created from scratch, you have to pick the type that makes the most sense for the situation. The

The checklist cannot be lengthy. A rule of thumb some use is to keep it to between five and nine items, which is the limit of working memory.

Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is.

jump-start the heart,

the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.

All the examples, I noticed, had a few attributes in common: They involved simple interventions—a vaccine, the removal of a pump handle. The effects were carefully measured. And the interventions proved to have widely transmissible benefits—what business types would term a large ROI (return on investment) or what Archimedes would have called, merely, leverage.

people who don’t know one another’s names don’t work together nearly as well as those who do.

By the century’s end, all doctors had to have a college degree, a four-year medical degree, and an additional three to seven years of residency training in an individual field of practice—pediatrics, surgery, neurology, or the like. In recent years, though, even this level of preparation has not been enough for the new complexity of medicine. After their residencies, most young doctors today are going on to do fellowships, adding one to three further years of training in, say, laparoscopic surgery, or pediatric metabolic disorders, or breast radiology, or critical care.

Discipline is hard—harder than trustworthiness and skill and perhaps even than selflessness. We are by nature flawed and inconstant creatures. We can’t even keep from snacking between meals. We are not built for discipline. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.

You must decide whether you want a DO-CONFIRM checklist or a READ-DO checklist. With a DO-CONFIRM checklist, he said, team members perform their jobs from memory and experience, often separately. But then they stop. They pause to run the checklist and confirm that everything that was supposed to be done was done. With a READ-DO checklist, on the other hand, people carry out the tasks as they check them off—it’s more like a recipe.

The checklist cannot be lengthy. A rule of thumb some use is to keep it to between five and nine items, which is the limit of working memory. Boorman didn’t think one had to be religious on this point. “It

So you want to keep the list short by focusing on what he called “the killer items”—the steps that are most dangerous to skip and sometimes overlooked nonetheless.

The wording should be simple and exact, Boorman went on, and use the familiar language of the profession. Even the look of the checklist matters. Ideally, it should fit on one page. It should be free of clutter and unnecessary colors. It should use both uppercase and lowercase text for ease of reading. (He went so far as to recommend using a sans serif type like Helvetica.)

First drafts always fall apart, he said, and one needs to study how, make changes, and keep testing until the checklist works consistently

An inherent tension exists between brevity and effectiveness. Cut too much and you won’t have enough checks to improve care. Leave too much in and the list becomes too long to use.

Training in most fields is longer and more intense than ever. People spend years of sixty-, seventy-, eighty-hour weeks building their base of knowledge and experience before going out into practice on their own—whether they are doctors or professors or lawyers or engineers. They have sought to perfect themselves. It is not clear how we could produce substantially more expertise than we already have. Yet our failures remain frequent. They persist despite remarkable individual ability. *

An inherent tension exists between brevity and effectiveness. Cut too much and you won’t have enough checks to improve care. Leave too much in and the list becomes too long to use. Furthermore,

It’s easy to hide in a statement. It’s hard to hide between statements,” Cook said.

Medicine has become the art of managing extreme complexity—and a test of whether such complexity can, in fact, be humanly mastered. The

the real lesson is that under conditions of true complexity—where the knowledge required exceeds that of any individual and unpredictability reigns—efforts to dictate every step from the center will fail. People need room to act and adapt. Yet

Teamwork may just be hard in certain lines of work. Under conditions of extreme complexity, we inevitably rely on a division of tasks and expertise—in the operating room, for example, there is the surgeon, the surgical assistant, the scrub nurse, the circulating nurse, the anesthesiologist, and so on. They can each be technical masters at what they do. That’s what we train them to be, and that alone can take years. But the evidence suggests we need them to see their job not just as performing their isolated set of tasks well but also as helping the group get the best possible results. This requires finding a way to ensure that the group lets nothing fall between the cracks and also adapts as a team to whatever problems might arise.

It is common to misconceive how checklists function in complex lines of work. They are not comprehensive how-to guides, whether for building a skyscraper or getting a plane out of trouble. They are quick and simple tools aimed to buttress the skills of expert professionals. And

under conditions of complexity, not only are checklists a help, they are required for success. There must always be room for judgment, but judgment aided—and even enhanced—by procedure.

no matter how careful we might be, no matter how much thought we might put in, a checklist has to be tested in the real world, which is inevitably more complicated than expected. First drafts always fall apart, he said, and one needs to study how, make changes, and keep testing until the checklist works consistently.

A young doctor is not so young nowadays; you typically don’t start in independent practice until your midthirties. We

It was also a checklist, but it didn’t specify construction tasks; it specified communication tasks. For the way the project managers dealt with the unexpected and the uncertain was by making sure the experts spoke to one another—on X date regarding Y process. The experts could make their individual judgments, but they had to do so as part of a team that took one another’s concerns into account, discussed unplanned developments, and agreed on the way forward. While no one could anticipate all the problems, they could foresee where and when they might occur. The checklist therefore detailed who had to talk to whom, by which date, and about what aspect of construction—who had to share (or “submit”) particular kinds of information before the next steps could proceed.

This is the reality of intensive care: at any point, we are as apt to harm as we are to heal. Line infections are so common that they are considered a routine complication. ICUs put five million lines into patients each year, and national statistics show that after ten days 4 percent of those lines become infected. Line infections occur in eighty thousand people a year in the United States and are fatal between 5 and 28 percent of the time, depending on how sick one is at the start. Those who survive line infections spend on average a week longer in intensive care.

Surgery has, essentially, four big killers wherever it is done in the world: infection, bleeding, unsafe anesthesia, and what can only be called the unexpected. For the first three, science and experience have given us some straightforward and valuable preventive measures we think we consistently follow but don’t. These misses are simple failures—perfect for a classic checklist.

the 36 percent increase between 2004 and 2007 in lawsuits against attorneys for legal mistakes—the most common being simple administrative errors, like missed calendar dates and clerical screwups, as well as errors in applying the law.

Before taxiing out to the runway, we paused again for five more checks: whether anti-icing was necessary and completed, the autobrakes were set, the flight controls were checked, the ground equipment was cleared, and no warning lights were on. The three checklists

Two professors who study the science of complexity—Brenda Zimmerman of York University and Sholom Glouberman of the University of Toronto—have proposed a distinction among three different kinds of problems in the world: the simple, the complicated, and the complex.

Thinking about averting plane crashes in 1935, or stopping infections of central lines in 2003, or rescuing drowning victims today, I realized that the key problem in each instance was essentially a simple one, despite the number of contributing factors.

Oh yes, he said. In a fire, the metal can plasticize—lose its stiffness and bend like spaghetti. This was why the World Trade Center buildings collapsed,

And that summer, as Hurricane Ella made its way toward the city, an emergency crew worked at night under veil of secrecy to weld two-inch-thick steel plates around the two hundred critical bolts, and the building was secured. The Citicorp tower has stood solidly ever since. The

Consider heart attacks. Even as recently as the 1950s, we had little idea of how to prevent or treat them. We didn’t know, for example, about the danger of high blood pressure, and had we been aware of it we wouldn’t have known what to do about it. The first safe medication to treat hypertension was not developed and conclusively demonstrated to prevent disease until the 1960s. We didn’t know about the role of cholesterol, either, or genetics or smoking or diabetes. Furthermore,

You see it in the 36 percent increase between 2004 and 2007 in lawsuits against attorneys for legal mistakes—the most common being simple administrative errors, like missed calendar dates and clerical screwups, as well as errors in applying the law. You see it in flawed software design, in foreign intelligence failures, in our tottering banks—in fact, in almost any endeavor requiring mastery of complexity and of large amounts of knowledge. Such

People spend years of sixty-, seventy-, eighty-hour weeks building their base of knowledge and experience before going out into practice on their own—whether they are doctors or professors or lawyers or engineers. They have sought to perfect themselves.

And there is such a strategy—though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies. It is a checklist.

But finding a good idea is apparently not all that hard. Finding an entrepreneur who can execute a good idea is a different matter entirely. One needs a person who can take an idea from proposal to reality, work the long hours, build a team, handle the pressures and setbacks, manage technical and people problems alike, and stick with the effort for years on end without getting distracted or going insane. Such people are rare and extremely hard to spot. Smart

I cannot pretend he escaped unscathed. The extended period of low blood pressure damaged an optic nerve and left him essentially blind in one eye. He didn’t get off the respirator for days. He was out of work for months. I was crushed by what I had put him through. Though I apologized to him and carried on with my daily routine, it took me a long time to feel right again in surgery. I can’t do an adrenalectomy without thinking of his case, and I suspect that is good. I have even tried refining the operative technique

Instead, they came up with an ingeniously simple approach: they created a pilot’s checklist. Its mere existence indicated how far aeronautics had advanced. In the early years of flight, getting an aircraft into the air might have been nerve-racking but it was hardly complex. Using a checklist for takeoff would no more have occurred to a pilot than to a driver backing a car out of the garage. But flying this new plane was too complicated to be left to the memory of any one person, however expert. The test pilots made their list simple, brief, and to the point—short enough to fit on an index card, with step-by-step checks for takeoff, flight, landing, and taxiing. It had the kind of stuff that all pilots know to do. They check that the brakes are released, that the instruments are set, that the door and windows are closed, that the elevator controls are unlocked—dumb stuff. You wouldn’t think it would make that much difference. But with the checklist in hand, the pilots went on to fly the Model 299 a total of 1.8 million miles without one accident. The army ultimately ordered almost thirteen thousand of the aircraft, which it dubbed the B-17. And, because flying the behemoth was now possible, the army gained a decisive air advantage in the Second World War, enabling its devastating bombing

Если бы все решали инженеры, то все здания были бы прямоугольными коробками

Многообразие и сложность строительной индустрии на всех этапах значительно превосходили возможности одного человека

A political/relational model of disability, on the other hand, makes room for more activist responses, seeing “disability” as a potential site for collective reimagining. Under this kind of framework, “disability awareness” simulations can be reframed to focus less on the individual experience of disability—or imagined experience of disability—and more on the political experience of disablement. For example, rather than placing nondisabled students in wheelchairs, the Santa Barbara-based organization People in Search of Safe and Accessible Restrooms (PISSAR) places them in bathrooms, armed with measuring tapes and clipboards, to track the failures and omissions of the built environment. As my fellow restroom revolutionaries explain in our manifesto, “This switch in focus from the inability of the body to the inaccessibility of the space makes room for activism and change in ways that ‘awareness exercises’ may not.” In creating and disseminating a “restroom checklist,” PISSAR imagines a future of disability activism, one with disability rights activists demanding accessible spaces; contrast that approach with the simulation exercises, in which “awareness” is the future goal, rather than structural or systemic change.

معمولاً همه از نحوه عملکرد چک‌لیست در شرایط پیچیده کاری، تصور غلطی دارند. آنها راهنماهای جامع نیستند، چه برای ساخت یک آسمان‌خراش یا حل مشکل یک هواپیما. آنها ابزاری سریع و ساده هستند که هدفشان پشتیبانی از مهارت‌های متخصصین حرفه‌ای است. و با توجه به سریع و کاربردی بودنشن، جان هزاران هزاران نفر را نجات می‌دهند.

On any given day in the United States alone, some ninety thousand people are admitted to intensive care. Over a year, an estimated five million Americans will be, and over a normal lifetime nearly all of us will come to know the glassed bay of an ICU from the inside. Wide swaths of medicine now depend on the life support systems that ICUs provide: care for premature infants; for victims of trauma, strokes, and heart attacks; for patients who have had surgery on their brains, hearts, lungs, or major blood vessels. Critical care has become an increasingly large portion of what hospitals do. Fifty years ago, ICUs barely existed. Now, to take a recent random day in my hospital, 155 of our almost 700 patients are in intensive care. The average stay of an ICU patient is four days, and the survival rate is 86 percent. Going into an ICU, being put on a mechanical ventilator, having tubes and wires run into and out of you, is not a sentence of death. But the days will be the most precarious of your life.

There are good checklists and bad, Boorman explained. Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat the people using the tools as dumb and try to spell out every single step. They turn people’s brains off rather than turn them on. Good checklists, on the other hand, are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything—a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps—the ones that even the highly skilled professionals using them could miss. Good checklists are, above all, practical.

But finding a good idea is apparently not all that hard. Finding an entrepreneur who can execute a good idea is a different matter entirely. One needs a person who can take an idea from proposal to reality, work the long hours, build a team, handle the pressures and setbacks, manage technical and people problems alike, and stick with the effort for years on end without getting distracted or going insane. Such people are rare and extremely hard to spot.

We are by nature flawed and inconstant creatures. We can’t even keep from snacking between meals. We are not built for discipline. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.

the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us. That means we need a different strategy for overcoming failure, one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our inevitable human inadequacies. And there is such a strategy—though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies. It is a checklist.

The second type of failure the philosophers call ineptitude—because in these instances the knowledge exists, yet we fail to apply it correctly.

Medicine has become the art of managing extreme complexity.