The Checklist Manifesto_ How to Get Things Right - Atul Gawande [80]
59 “We’ve been slow to adapt”: Data from the Dartmouth Atlas of Health Care, www.darmouthatlas.org.
69 “It was planned to rise”: R. J. McNamara, “Robert J. McNamara, SE, FASCE,” Structural Design of Tall and Special Buildings 17 (2008): 493–512.
70 “But, as a New Yorker story”: Joe Morgenstern, “The Fifty-Nine-Story Crisis,” New Yorker, May 29, 1995.
71 “In the United States”: U.S. Census data for 2003 and 2008, www.census.gov; K. Wardhana and F. C. Hadipriono, “Study of Recent Building Failures in the United States,” Journal of Performance of Constructed Facilities 17 (2003): 151–58.
4. THE IDEA
73 “At 6:00 a.m.”: Hurricane Katrina events and data from E. Scott, “Hurricane Katrina,” Managing Crises: Responses to Large-Scale Emergencies, ed. A. M. Howitt and H. B. Leonard (Washington, D.C.: CQ Press, 2009), pp. 13–74.
76 “Of all organizations”: Wal-Mart events and data from S. Rose -grant, “Wal-Mart’s Response to Hurricane Katrina,” Managing Crises, pp. 379–406.
78 “For every Wal-Mart”: D. Gross, “What FEMA Could Learn from Wal-Mart: Less Than You Think,” Slate, Sept. 23, 2005, http://www.slate.com/id/2126832.
78 “In the early days”: Scott, “Hurricane Katrina,” p. 49.
80 “As Roth explained”: D. L. Roth, Crazy from the Heat (New York: Hyperion, 1997).
81 “Her focus is on regional Italian cuisine”: J. Adams and K. Rivard, In the Hands of a Chef: Cooking with Jody Adams of Rialto Restaurant (New York: William Morrow, 2002).
5. THE FIRST TRY
87 “By 2004”: T. G. Weiser et al., “An Estimation of the Global Volume of Surgery: A Modelling Strategy Based on Available Data,” Lancet 372 (2008): 139–44.
87 “Although most of the time”: A. A. Gawande et al., “The Incidence and Nature of Surgical Adverse Events in Colorado and Utah in 1992,” Surgery 126 (1999): 66–75.
87 “Worldwide, at least seven million people”: Weiser, “An Estimation,” and World Health Organization, World Health Report, 2004 (Geneva: WHO, 2004). See annex, table 2.
91 “The strategy has shown results”: P. K. Lindenauer et al., “Public Reporting and Pay for Performance in Hospital Quality Improvement,” New England Journal of Medicine 356 (2007): 486–96.
93 “When the disease struck”: S. Johnson, The Ghost Map (New York: Riverhead, 2006).
95 “Luby and his team reported”: S. P. Luby et al., “Effect of Hand-washing on Child Health: A Randomised Controlled Trial,” Lancet 366 (2005): 225–33.
98 “But give it on time”: A. A. Gawande and T. G. Weiser, eds., World Health Organization Guidelines for Safe Surgery (Geneva: WHO, 2008).
102 “In one survey of three hundred”: M. A. Makary et al., “Operating Room Briefings and Wrong-Site Surgery,” Journal of the American College of Surgeons 204 (2007): 236–43.
102 “surveyed more than a thousand”: J. B. Sexton, E. J. Thomas, and R. L. Helmsreich, “Error, Stress, and Teamwork in Medicine and Aviation,” British Medical Journal 320 (2000): 745–49.
108 “The researchers learned”: See preliminary data reported in “Team Communication in Safety,” OR Manager 19, no. 12 (2003): 3.
109 “After three months”: Makary et al., “Operating Room Briefings and Wrong-Site Surgery.”
109 “At the Kaiser hospitals”: “ ‘Preflight Checklist’ Builds Safety Culture, Reduces Nurse Turnover,” OR Manager 19, no. 12 (2003): 1–4.
109 “At Toronto”: L. Lingard et al. “Getting Teams to Talk: Development and Prior Implementation of a Checklist to Promote Interpersonal Communication in the OR,” Quality and Safety in Health Care 14 (2005): 340–46.
6. THE CHECKLIST FACTORY
114 “Among the articles I found”: D. J. Boorman, “Reducing Flight Crew Errors and Minimizing New Error Modes with Electronic Checklists,” Proceedings of the International Conference on Human-Computer Interaction in Aeronautics (Toulouse: Editions Cépaudès, 2000), pp. 57–63; D. J. Boorman, “Today’s Electronic Checklists Reduce Likelihood of Crew Errors and Help Prevent Mishaps,” ICAO Journal 56 (2001): 17–20.
116 “An electrical short”: National Traffic Safety Board, “Aircraft Accident Report: Explosive Decompression—Loss