The Checklist Manifesto_ How to Get Things Right - Atul Gawande [13]
Still, the army purchased a few aircraft from Boeing as test planes, and some insiders remained convinced that the aircraft was flyable. So a group of test pilots got together and considered what to do.
What they decided not to do was almost as interesting as what they actually did. They did not require Model 299 pilots to undergo longer training. It was hard to imagine having more experience and expertise than Major Hill, who had been the air corps’ chief of flight testing. 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 campaign across Nazi Germany.
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. We may admit that errors and oversights occur—even devastating ones. But we believe our jobs are too complicated to reduce to a checklist. Sick people, for instance, are phenomenally more various than airplanes. A study of forty-one thousand trauma patients in the state of Pennsylvania—just trauma patients—found that they had 1,224 different injury-related diagnoses in 32,261 unique combinations. That’s like having 32,261 kinds of airplane to land. Mapping out the proper steps for every case is not possible, and physicians have been skeptical that a piece of paper with a bunch of little boxes would improve matters.
But we have had glimmers that it might, at least in some corners. What, for instance, are the vital signs that every hospital records if not a kind of checklist? Comprised of four physiological data points—body temperature, pulse, blood pressure, and respiratory rate—they give health professionals a basic picture of how sick a person is. Missing one of these measures can be dangerous, we’ve learned. Maybe three of them seem normal—the patient looks good, actually—and you’re inclined to say, “Eh, she’s fine, send her home.” But perhaps the fourth reveals a fever or low blood pressure or a galloping heart rate, and skipping it could cost a person her life.
Practitioners have