10 November 2020


In this post we shine a spotlight on the unassuming, seemingly unsexy checklist and why it is a powerful tool for reducing errors by dealing with the limitations of our brain.


Whether you’re launching a rocket, flying a Boeing, or building a skyscraper, checklists have become an essential ingredient for error reduction and have been proven to literally save lives. Books and a podcast (which is the source of inspiration for this piece!) have been devoted to lauding the checklist.


Even experts need checklists

Checklists are at their most powerful when they are used by experts. They mitigate the mental bias in humans where repetitive activities become routine, leading to the risk that small, but critical, steps are missed.

A case study and modern rebirth story about the power of the checklist is the story of the Flying Fortress. The 1935 crash of this Boeing aircraft was caused by the pilots forgetting to unlock the elevator before take off resulting in the aircraft pitching upward. The pilots were unable to level off and the aircraft crashed. The US military insightfully responded to the event not with additional training, but with a tool that would be instrumental in changing aviation safety – the checklist.

The military recognised that providing more training to expert pilots would not address the root cause of the error. The pilots involved in this crash were highly trained, highly experienced and competent. They were so experienced and sure of what they were doing that they missed routine steps. This is the exact situation where the checklist is a hero.

Atul Gawunde, author of The Checklist Manifesto, speaks of a study he conducted that involved developing a basic surgical checklist. He was motivated to conduct this study after examining data that indicated that the major cause of disability or death in surgical patients was related to a problem where the answer was known, however not executed upon. Gawunde finds that only a small percentage of disability or death in surgical patients was due to a problem where the answer was unknown. The failure was in the execution, not the knowledge. Gawunde and his team developed a basic surgical checklist and trialed it with surgical teams in 8 cities around the world. The average reduction in complications was 35 percent. The reduction in deaths was 47 percent.

The steps in the surgical checklist were elegant in their simplicity; Has the patient confirmed their identity and the procedure prior to the induction of anaesthesia? Has the surgical team introduced themselves to one another by name and role before making an incision? These small steps may be obvious and easily overlooked. A checklist helps to ensure these small, important steps occur each and every time.


Involve the experts

Checklists are most effective when they are designed and implemented in parallel with the teams who will be using them to ensure they are practical.

Anaesthesiologist Peter Pronovost, upon seeing the number of people dying from infections despite existing checklists, sought to understand the root causes for non-compliance at John Hopkins Hospital in Maryland. While the existing checklist required medical staff to use PPE, alcohol swabs and drapes, a key pain point he identified was that supplies were stocked in eight different places adding precious time to operation preparation. Medical teams were choosing timeliness over managing an “invisible” risk of infection that may not manifest.  Supplies were located to a centralised and accessible cart and replenished regularly. This action saw checklist compliance improve from 30% to 75%.


Culture matters

In his book, Peter Pronovost identified that a power dynamic was also impacting checklist adherence. Doctors did not want to be called out for not following agreed procedures in the operating theatre and nurses were reluctant to challenge the doctors they were working with. Pronovost brought the teams together to agree one central principle – ensuring patient safety and care. In getting this buy-in and addressing culture, checklist compliance increased from 75% to 98% and infection rates more than halved.

Gawunde’s research identified similar cultural considerations. Introducing surgical checklists was only part of the solution, another part was understanding the culture of the workplace. Differing approaches were taken by hospitals in Ottawa and South Carolina. In Ottawa the checklist was mandated by law with hospitals attesting that they had followed the checklist. A change management program was not put in place. The result was little improvement in patient death outcomes. In South Carolina extensive consultation was undertaken including one on one sessions to ensure teams understood why the checklist was being implemented and encouraging hospitals to make the checklist their own. South Carolina hospitals involved in the program saw a 22% reduction in patient deaths.


The makings of a good checklist

A good checklist should:

  • Focus on the areas or processes where mistakes occur most frequently;
  • Be chunked into 5 to 9 steps;
  • Be designed by the teams that use them – not administrators or control functions that could them unnecessarily lengthy and unusable; and
  • Use succinct, direct, even terse, language.


The learnings from the experiences of Pronovost and Gawunde are equally relevant outside of the medical sector. Again, culture comes to the fore when seeking to manage risk. And an agreed shared purpose helps underscore the importance for all members of the team. The local environment and context need to be understood.  With changes in business practices and advancements in technology, it is worthwhile remembering the humble checklist still has pride of place when it comes to managing risk.


tanushree@px.partners is an avid fan of the checklist and has applied the pervasive rigour of PX Partners to support clients with framework & control design and implementation.