The Checklist Manifesto_ How to Get Things Right - Atul Gawande [0]
BETTER: A SURGEON’S NOTES ON PERFORMANCE
COMPLICATIONS: A SURGEON’S NOTES ON AN IMPERFECT SCIENCE
THE CHECKLIST MANIFESTO
ATUL GAWANDE
THE CHECKLIST MANIFESTO: HOW TO GET THINGS RIGHT
METROPOLITAN BOOKS HENRY HOLT AND COMPANY NEW YORK
Metropolitan Books
Henry Holt and Company, LLC
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New York, New York 10010
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Metropolitan Books® and ® are registered trademarks
of Henry Holt and Company, LLC.
Copyright © 2009 by Atul Gawande
All rights reserved.
Distributed in Canada by H. B. Fenn and Company Ltd.
Some material in this book originally appeared in the
New Yorker essay “The Checklist” in different form.
Library of Congress Cataloging-in-Publication data are available.
ISBN: 978-0-8050-9174-8
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and premiums. For details contact: Director, Special Markets.
First Edition 2010
Designed by Meryl Sussman Levavi
Printed in the United States of America
1 2 3 4 5 6 7 8 9 10
For Hunter, Hattie, and Walker
CONTENTS
INTRODUCTION
1. THE PROBLEM OF EXTREME COMPLEXITY
2. THE CHECKLIST
3. THE END OF THE MASTER BUILDER
4. THE IDEA
5. THE FIRST TRY
6. THE CHECKLIST FACTORY
7. THE TEST
8. THE HERO IN THE AGE OF CHECKLISTS
9. THE SAVE
NOTES ON SOURCES
ACKNOWLEDGMENTS
THE CHECKLIST MANIFESTO
INTRODUCTION
I was chatting with a medical school friend of mine who is now a general surgeon in San Francisco. We were trading war stories, as surgeons are apt to do. One of John’s was about a guy who came in on Halloween night with a stab wound. He had been at a costume party. He got into an altercation. And now here he was.
He was stable, breathing normally, not in pain, just drunk and babbling to the trauma team. They cut off his clothes with shears and looked him over from head to toe, front and back. He was of moderate size, about two hundred pounds, most of the excess around his middle. That was where they found the stab wound, a neat two-inch red slit in his belly, pouting open like a fish mouth. A thin mustard yellow strip of omental fat tongued out of it—fat from inside his abdomen, not the pale yellow, superficial fat that lies beneath the skin. They’d need to take him to the operating room, check to make sure the bowel wasn’t injured, and sew up the little gap.
“No big deal,” John said.
If it were a bad injury, they’d need to crash into the operating room—stretcher flying, nurses racing to get the surgical equipment set up, the anesthesiologists skipping their detailed review of the medical records. But this was not a bad injury. They had time, they determined. The patient lay waiting on his stretcher in the stucco-walled trauma bay while the OR was readied.
Then a nurse noticed he’d stopped babbling. His heart rate had skyrocketed. His eyes were rolling back in his head. He didn’t respond when she shook him. She called for help, and the members of the trauma team swarmed back into the room. His blood pressure was barely detectible. They stuck a tube down his airway and pushed air into his lungs, poured fluid and emergency-release blood into him. Still they couldn’t get his pressure up.
So now they were crashing into the operating room—stretcher flying, nurses racing to get the surgical equipment set up, the anesthesiologists skipping their review of the records, a resident splashing a whole bottle of Betadine antiseptic onto his belly, John grabbing a fat No. 10 blade and slicing down through the skin of the man’s abdomen in one clean, determined swipe from rib cage to pubis.
“Cautery.”
He drew the electrified metal tip of the cautery pen along the fat underneath the skin, parting it in a line from top to bottom, then through the fibrous white sheath of fascia between the abdominal muscles. He pierced his way into the abdominal cavity itself, and suddenly an ocean of blood burst out of the patient.
“Crap.”
The blood was everywhere. The assailant’s knife had gone