The Checklist Manifesto_ How to Get Things Right - Atul Gawande [81]
116 “The plane was climbing”: S. White, “Twenty-Six Minutes of Terror,” Flight Safety Australia, Nov.–Dec. 1999, pp. 40–42.
120 “They can help experts”: A. Degani and E. L. Wiener, “Human Factors of Flight-Deck Checklists: The Normal Checklist,” NASA Contractor Report 177549, Ames Research Center, May 1990.
121 “Some have been found confusing”: Aviation Safety Reporting System, “ASRS Database Report Set: Checklist Incidents,” 2009.
129 “Crash investigators with Britain’s”: Air Accidents Investigation Branch, “AAIB Interim Report: Accident to Boeing 777-236ER, G-YMMM, at London Heathrow Airport on 17 January 2008,” Department of Transport, London, Sept. 2008.
129 “ ‘It was just yards above’ ”: M. Fricker, “Gordon Brown Just 25 Feet from Death in Heathrow Crash,” Daily Mirror, Jan. 18, 2008.
129 “The nose wheels collapsed”: Air Accidents Investigation Branch, “AAIB Bulletin S1/2008,” Department of Transport, London, Feb. 2008.
130 “Their initial reports”: Air Accidents Investigation Branch, “AAIB Bulletin S1/2008”; Air Accidents Investigation Branch, “AAIB Bulletin S3/2008,” Department of Transport, London, May 2008.
132 “Nonetheless, the investigators tested”: Air Accidents Investigation Branch, “AAIB Interim Report.”
132 “So in September 2008”: Federal Aviation Administration, Airworthiness Directive; Boeing Model 777-200 and -300 Series Airplanes Equipped with Rolls-Royce Model RB211-TRENT 800 Series Engines, Washington, D.C., Sept. 12, 2008.
133 “One study in medicine”: E. A. Balas and S. A. Boren, “Managing Clinical Knowledge for Health Care Improvement,” Yearbook of Medical Informatics (2000): 65–70.
133 “almost 700,000 medical journal articles”: National Library of Medicine, “Key Medline Indicators,” Nov. 12, 2008, accessed at www.nlm.nih.gov/bsd/bsd_key.html.
134 “This time it was”: National Transportation Safety Board, “Safety Recommendations A-09-17-18,” Washington, D.C., March 11, 2009.
7. THE TEST
139 “Of the tens of millions”: Joint Commission, Sentinel Event Alert, June 24, 2003.
139 “By comparison, some 300,000”: R. D. Scott, “The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention,” Centers for Disease Control, March 2009.
140 “The final WHO safe surgery checklist”: The checklist can be accessed at www.who.int/safesurgery.
146 “We gave them some PowerPoint slides”: The videos can be viewed at www.safesurg.org/materials.html.
156 “In January 2009”: A. B. Haynes et al., “A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population,” New England Journal of Medicine 360 (2009): 491–99.
8. THE HERO IN THE AGE OF CHECKLISTS
161 “Tom Wolfe’s The Right Stuff”: T. Wolfe, The Right Stuff (New York: Farrar, Straus and Giroux, 1979).
163 “Neuroscientists have found”: H. Breiter et al., “Functional Imaging of Neural Responses to Expectancy and Experience of Monetary Gains and Losses,” Neuron 30 (2001): 619–39.
166 “ ‘Cort’s earning power’ ”: Wesco Financial Corporation, Securities and Exchange Commission, Form 8-K filing, May 4, 2005.
170 “Smart specifically studied”: G. H. Smart, “Management Assessment Methods in Venture Capital: An Empirical Analysis of Human Capital Valuation,” Journal of Private Equity 2, no. 3 (1999): 29–45.
172 “He has since gone on”: G. H. Smart and R. Street, Who: The A Method for Hiring (New York: Ballantine, 2008).
173 “A National Transportation Safety Board official”: J. Olshan and I. Livingston, “Quiet Air Hero Is Captain America,” New York Post, Jan. 17, 2009.
174 “As Sullenberger kept saying”: M. Phillips, “Sully, Flight 1549 Crew Receive Keys to New York City,” The Middle Seat, blog, Wall Street Journal, Feb. 9, 2009, http://blogs.wsj.com/middleseat/2009/02/09/.
174 “ ‘That was so long ago’ ”: “Sully’s Tale,” Air & Space, Feb. 18, 2009.
178 “Once that happened”: C. Sullenberger