The Checklist Manifesto_ How to Get Things Right - Atul Gawande [82]
179 “Skiles managed to complete”: Testimony of Captain Terry Lutz, Experimental Test pilot, Engineering Flight Operations, Airbus, National Transportation Safety Board, “Public Hearing in the Matter of the Landing of US Air Flight 1549 in the Hudson River, Weehawken, New Jersey, January 15, 2009,” June 10, 2009.
180 “ ‘Flaps out?’ ”: D. P. Brazy, “Group Chairman’s Factual Report of Investigation: Cockpit Voice Recorder DCA09MA026,” National Transportation Safety Board, April 22, 2009.
180 “For, as journalist and pilot”: W. Langewiesche, “Anatomy of a Miracle,” Vanity Fair, June 2009.
181 “After the plane landed”: Testimony of Captain Chesley Sullenberger, A320 Captain, US Airways, National Transportation Safety Board, Public Hearing, June 9, 2009.
ACKNOWLEDGMENTS
Three kinds of people were pivotal to this book: the ones behind the writing, the ones behind the ideas, and the ones who made both possible. As the book involved background research in several fields beyond my expertise, the number of people I am indebted to is especially large. But this book could never have been completed without all of them.
First are those who helped me take my loose observations about failure and checklists and bring them together in book form. My agent, Tina Bennett, saw the possibilities right away and championed the book from the moment I first told her about my burgeoning fascination with checklists. My editor at the New Yorker, the indispensable Henry Finder, showed me how to give my initial draft more structure and my thinking more coherence. Laura Schoenherr, my brilliant and indefatigable research assistant, found almost every source here, checked my facts, provided suggestions, and kept me honest. Roslyn Schloss provided meticulous copyediting and a vital final review. At Metropolitan Books, Riva Hocherman went through the text with inspired intelligence and gave crucial advice at every stage of the book’s development. Most of all, I leaned on Sara Bershtel, Metropolitan’s publisher, with whom I’ve worked for nearly a decade now. Smart, tough, and tireless, she combed through multiple drafts, got me to sharpen every section, and saved me from numerous errors of tone and thinking, all the while shepherding the book through production with almost alarming efficiency.
As for the underlying ideas and the stories and experience fleshing them out, I have many, many to thank. Donald Berwick taught me the science of systems improvement and opened my eyes to the possibilities of checklists in medicine. Peter Pronovost provided a crucial source of ideas with his seminal work in ICUs. Lucian Leape, David Bates, and Berwick were the ones to suggest my name to the World Health Organization. Sir Liam Donaldson, the chair of WHO Patient Safety, who established the organization’s global campaign to reduce deaths in surgery, was kind enough to bring me aboard to lead it and then showed me what leadership in public health really meant. Pauline Philip, the executive director of WHO Patient Safety, didn’t take no for an answer from me and proved extraordinary in both her dedication and her effectiveness in carrying out work that has now extended across dozens of countries.
At WHO, Margaret Chan, the director general, as well as Ian Smith, her adviser, David Heymann, deputy director general, and Tim Evans, assistant director general, have all been stalwart supporters. I am also particularly grateful to Gerald Dziekan, whom I have worked with almost daily for the past three years, and also Vivienne Allan, Hilary Coates, Armorel Duncan, Helen Hughes, Sooyeon Hwang, Angela Lashoher, Claire Lemer, Agnes Leotsakos, Pat Martin, Douglas Noble, Kristine Stave, Fiona Stewart-Mills, and Julie Storr.
At Boeing, Daniel Boorman emerged as an essential partner in work that has now extended to designing, testing, and implementing clinical checklists for safe childbirth, control of diarrheal infections, operating room crises, management of patients