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Summary The Checklist Manifesto by Atul Gawande
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- Summary -The Checklist Manifesto - Atul Gawande
1. Intro
NECESSARY FALLIBILITY
philosophers Samuel Gorovitz + Alasdair MacIntyre
some things we want to do are simply beyond our
capacity
We are not omniscient or all-powerful.
Even enhanced by technology, our physical and mental
powers are limited. Much of the world and universe is-
-and will remain--outside our understanding and control.
FAIL REASONS
1. IGNORANCE
PARTIAL UNDERSTANDING
Failures of ignorance we can forgive.
Mistakes we make because we don’t know enough
Not knowing enough about what works
2. INEPTITUDE
Knowledge exists, yet we fail to apply it correctly
But if the knowledge exists and is not applied correctly, it
is difficult not to be infuriated.
Negligence
Heartlessness
Mistakes we made because we don’t make proper use of
what we know
Not properly applying what we know works
POTASSIUM LEVELS
LOW --> STOP HEART
HIGH --> STOP HEART --> EXECUTION PRISONERS
, 2. THE PROBLEM OF EXTREME COMPLEXITY
World Health Organization's international classification of diseases
>= 13 000 different diseases, syndromes, and types of
injury
>= 13 000 different ways that the body can fail
6 000 drugs + 4 000 medical + surgical procedures
Different requirements, risks, and considerations
>= 2 500 DIFFERENT SURGICAL PROCEDURES
3. THE CHECKLIST
Test flight: Boeing Model 299 - flying fortress
October 30, 1935, at Wright Air Field in Dayton, Ohio
Two of the five crew members died, including the pilot,
Major Ployer P. Hill.
nothing mechanical had gone wrong
Hill had forgotten to release a new locking mechanism
on the elevator and rudder controls.
"too much airplane for one man to fly."
==> creation pilot's checklist
SIMPLE
BRIEF
TO-THE-POINT
Fit on an index card
Step-by-step checks
takeoff, flight, landing, and taxiing
Went on to fly the Model 299 a total of 1.8 million miles without
one accident
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