The Checklist Manifesto_ How to Get Things Right - Atul Gawande [5]
But what is striking about John’s cases is that he is among the best-trained surgeons I know, with more than a decade on the front lines. And this is the common pattern. The capability of individuals is not proving to be our primary difficulty, whether in medicine or elsewhere. Far from it. 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.
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 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.
*Identifying details were changed at John’s request.
1. THE PROBLEM OF EXTREME COMPLEXITY
Some time ago I read a case report in the Annals of Thoracic Surgery. It was, in the dry prose of a medical journal article, the story of a nightmare. In a small Austrian town in the Alps, a mother and father had been out on a walk in the woods with their three-year-old daughter. The parents lost sight of the girl for a moment and that was all it took. She fell into an icy fishpond. The parents frantically jumped in after her. But she was lost beneath the surface for thirty minutes before they finally found her on the pond bottom. They pulled her to the surface and got her to the shore. Following instructions from an emergency response team reached on their cell phone, they began cardiopulmonary resuscitation.
Rescue personnel arrived eight minutes later and took the first recordings of the girl’s condition. She was unresponsive. She had no blood pressure or pulse or sign of breathing. Her body temperature was just 66 degrees. Her pupils were dilated and unreactive to light, indicating cessation of brain function. She was gone.
But the emergency technicians continued CPR anyway. A helicopter took her to the nearest hospital, where she was wheeled directly into an operating room, a member of the emergency crew straddling her on the gurney, pumping her chest. A surgical team got her onto a heart-lung bypass machine as rapidly as it could. The surgeon had to cut down through the skin of the child’s right groin and sew one of the desk-size machine’s silicone rubber tubes into her femoral artery to take the blood out of her, then another into her femoral vein to send the blood back. A perfusionist turned the pump on, and as he adjusted the oxygen and temperature and flow through the system, the clear tubing turned maroon with her blood. Only then did they stop the girl’s chest compressions.
Between the transport time and the time it took to plug the machine into her, she had been lifeless for an hour and a half. By the two-hour