40 pages • 1 hour read
Atul GawandeThe Checklist Manifesto: How to Get Things Right
Nonfiction | Book | Adult | Published in 2009A modern alternative to SparkNotes and CliffsNotes, SuperSummary offers high-quality Study Guides with detailed chapter summaries and analysis of major themes, characters, and more.
Chapters 2-3Chapter Summaries & Analyses
Chapter 2 Summary: “The Checklist”
Chapter 2 begins with a foray into the world of aviation, as Gawande discusses the creation of the B-17 bomber. The B-17 bomber’s first flight in 1935 was much anticipated. When it came time for the first flight, the plane took off and soon crashed, killing two of the five-man crew. After an investigation, the cause of the crash was revealed to be a simple pilot error. With this incident came the development of the first pilot checklist. The B-17 bomber eventually regained its reputation and was used heavily against Nazi forces during WWII. Gawande mentions that in the context of complicated situations, humans make mistakes because they are either lulled by the mundane, or simply skip steps (resulting in an all-or-none process, in which skipping a single step compromises the whole endeavor). Skipping steps often happens due to internal circumstances, such as ego, and external pressures.
Gawande mentions Peter Pronovost, a renowned surgeon at Johns Hopkins Medical Center. Pronovost studied behaviors of surgeons and nurses when they used catheter lines on patients. He discovered that many life-threatening and fatal infections were the result of care professionals skipping one of five basic, but important steps prior to inserting the lines. He suggested developing a checklist to ensure these basics were covered. The use of checklists resulted in a dramatic decrease in patient infections from catheter lines. Pronovost then took his research and traveled around America. Some professionals saw Pronovost’s approach as insulting; at some hospitals, ICU doctors and nurses were so overwhelmed with patients, that the added steps of a checklist were seen as a secondary issue. However, Pronovost was able to convince the state of Michigan to adopt his checklists in ICU facilities. This decision was called the Keystone Initiative and proved successful, both in terms of reducing mistakes and saving hospitals millions of dollars. Gawande closes Chapter 2 by returning to the story of the three-year-old drowning victim from Austria (Chapter 1). He spoke with the girl’s lead cardiac surgeon, who indicated that a checklist performed by rescuers and sent in advance of patient arrival helped the hospital staff be better prepared for receiving her.
Chapter 3 Summary: “The End of the Master Builder”
Gawande begins Chapter 3 by acknowledging that though checklists are useful, they have limitations. He cites a claim made by two eminent scholars who study the science of complexity, which lists three types of problems: simple, complicated, and complex. Gawande provides real-world examples of each type. For simple problems, he mentions the process of baking a cake; if the cake recipe is followed, the probability of success is high. For complicated problems, he mentions sending a rocket ship to the moon; while many procedures are required of a rocket, and the chance of failure is high, once it is sent off, the process can be repeated to improve its success rate. For complex problems, he mentions raising a child; there are so many variables involved with raising a child that succeeding once does not guarantee a second success, even if a parent follows the same procedure twice. Raising a child is variable because no two people are alike. The medical field includes complex problems for the same reason.
Gawande addresses the utility of checklists in solving simple problems, but questions if checklists can handle complex problems. He delves into the construction industry and provides a detailed examination of how it handles complex problems to a high degree of success. He introduces Joe Salvia, a structural engineer from Boston. Gawande met with Salvia to learn how the construction of a skyscraper is undertaken by various trade specialists. Salvia mentions how for most of human history, the task of constructing a building was overseen by a “master builder.” In modern day, the master builder has been decentralized. In the age of specialization, this creates different challenges in which communication is critical. Gawande points out that in the medical field, the “master physician” is still the norm.
Gawande is given a tour of an in-progress building that Salvia’s firm has been working on called the Russia Wharf building. After meeting with the project supervisor, Finn O’Sullivan, Gawande recognizes that the firm relies heavily on a checklist for daily and weekly schedules. These checklists are highly detailed and itemized, meant to guide weekly work. As he is given the tour, Gawande sees pooling water on one of the exposed floors. This discovery reveals that even on a highly organized job site, there are always things that can go wrong. When Gawande discusses this with O’Sullivan, he learns that the firm handles unpredictable situations through a submittal schedule. This is a means through which both supervisors and workers can communicate anomalies large and small—which are later discussed by a job’s leaders. Gawande provides an example of a breakdown in communication, citing the Citicorp building in New York City. Salvia’s partner in his firm, Robert McNamara, was the structural engineer charged with the Citicorp building during its construction. After construction, it was discovered that the wrong type of joinery was used, which resulted in the building being less able to withstand high winds. This seemingly small but crucial mistake compromised the building and created a potentially dangerous situation. McNamara devised a solution to the problem, and the building has been stable ever since its completion in 1978. Gawande claims the construction industry’s success rate is impressive, due in part because it continues to find ways to refine communication that involves everyone who contributes to a project. This communication often relies on highly detailed and itemized checklists.
Chapters 2-3 Analysis
Gawande continues to explore the nature of complex problems and why mistakes happen. At the beginning of Chapter 2, Gawande makes his first foray into a different industry—aviation. After he recounts the failure of the original launch of the B-17 bomber, Gawande discusses people’s general tendencies in complex situations. He states, “In a complex environment, experts are up against two main difficulties. The first is the fallibility of human memory and attention, especially when it comes to mundane, routine matters” (35-36). Once the mundane takes hold, people fall into complacency, and this is often when critical mistakes happen—mistakes that are often avoidable. The anecdote of the B-17 illustrates this. The reason why the original flight ended in a crash was because the pilot overlooked a basic step for take-off. Likewise, the medical incidents described in the Introduction were caused by seemingly simple mistakes.
In Chapter 2, Gawande further illustrates how missing a basic step can compromise an endeavor, no matter the circumstances: “Faulty memory and distraction are a particular danger in what engineers call all-or-none processes […] if you miss just one key thing, you might as well not have made the effort at all” (36). As an answer to this problem, he offers the checklist as a solution: “[Checklists] remind us of the minimum necessary steps and make them explicit. They not only offer the possibility of verification but also instill a kind of discipline of higher performance” (36). He articulates the rationale for checklists, how they can improve performance despite their simplicity. Checklists help people stay focused and reduce the chances of simple mistakes.
In Chapter 3, Gawande continues his exploration of checklists and their use in other professions—in this case, the construction industry. After interviewing structural engineer Joe Salvia and his associate Finn O’Sullivan, Gawande gains deeper insight into the utility of the checklist. When Gawande visits Salvia’s construction site, he instinctively understands that this undertaking is enormous, and involves a wide range of considerations. Visiting the site reminds him that the finished product is entirely different from the work in progress. This leads to him developing questions about the process: “First, how could [construction workers] be sure that they had the right knowledge in hand? Second, how could they be sure that they were applying this knowledge correctly?” (53). These questions reveal Gawande’s willingness to truly understand the construction industry, and guide him in finding out how the industry deals with the unexpected. Checklists are vital in this industry. Considering the scope of the Russia Wharf building that he visits, Gawande is somewhat surprised to learn that Salvia’s firm uses “[…] a succession of day-by-day checks that guide how the building is constructed and ensure that the knowledge of hundreds, perhaps thousands, is put to use in the right place at the right time in the right way” (62). Witnessing the firm’s daily and weekly use of checklists in a real-world scenario is a significant moment for Gawande. When he draws parallels to his own profession, he realizes a discrepancy between construction and medicine when it comes to dealing with the unexpected: “The medical way of dealing with such problems—with the inevitable nuances of an individual patient case—is to leave them to the expert’s individual judgment” (64). The construction industry’s use of the checklist gives Gawande further insight into its utility, and his touring also highlights how the medical field is lacking.
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