“I read The Checklist Manifesto in one sitting yesterday, which is an amazing tribute to the book that Gawande has crafted. Not only is the book loaded with fascinating stories, but it honestly changed the way I think about the world. It is the best book I've read in ages.” ―Steven Levitt, author of Freakonomics

“Few medical writers working today can transmit the gore-drenched terror of an operation that suddenly goes wrong--a terror that has a special resonance when it is Dr. Gawande himself who makes the initial horrifying mistake. And few can make it as clear as he can what exactly is at stake in the effort to minimize calamities.” ―The New York Times

“Even skeptical readers will find the evidence staggering. . . . Thoughtfully written and soundly defended, this book calls for medical professionals to improve patient care by adopting a basic, common-sense approach.” ―The Washington Post

“A persuasive champion of his cause.” ―The Economist

“The Checklist Manifesto is beautifully written, engaging, and convincingly makes the case for adopting checklists in medicine, a project to which Gawande has devoted significant time over the last several years. . . . It is in many ways the most personal of his books, a direct call to action to change the way health care is delivered through straightforward and simple, yet proven, means. It is a call that deserves to be heard and heeded.” ―Journal of the American Medical Association

“Gawande deftly weaves in examples of checklist successes in diverse fields like aviation and skyscraper construction. . . . Fascinating reading.” ―New York Times Book Review

“This is a brilliant book about an idea so simple it sounds dumb until you hear the case for it. Atul Gawande presents an argument so strong that I challenge anyone to go away from this book unconvinced.” ―The Seattle Times

“Fascinating . . . presents a convincing case that adopting more checklists will surely help.” ―Bloomberg News

“Gawande argues convincingly and eloquently.” ―San Francisco Chronicle

“The scope goes well beyond medicine. . . Read this book and you might find yourself making checklists for the most mundane tasks--and be better off for it.” ―BusinessWeek

“A vivid, punchy exposition of an intriguing idea: that by-the-book routine trumps individual prowess.” ―Publishers Weekly

“Maintains the balance between accessibility and precision. He manages to be vivid without being gruesome. . . .” ―The Guardian (UK)

“Riveting and thought-provoking.” ―The Times (UK)

“Eye-popping. . . Gawande writes with vigor and clarity.” ―New Haven Advocate

“Gawande manages to capture medicine in all of its complex and chaotic glory, and to put it, still squirming with life, down on the page. With this book, Gawande inspires all of us, doctor or not, to be better.” ―The New York Times Book Review on Better

“Gawande is unassuming in every way, and yet his prose is infused with steadfast determination and hope. If society is the patient here, I can't think of a better guy to have our back.” ―The Boston Globe on Better

“Remarkable . . . Brings to modern high-tech medicine the same clinical watchfulness that writers such as Williams and Sacks have brought to bear on the lives and emotions of often fragile patients.” ―Sherwin B. Nuland, The New York Review of Books, on Better

“Gawande is a writer with a scalpel pen and an X-ray eye. Diagnosis: riveting.” ―TIME, on Better

Atul Gawande is the author of four bestselling books: Complications, a finalist for the National Book Award; Better; The Checklist Manifesto, and Being Mortal. He is also a surgeon at Brigham and Women's Hospital in Boston, a staff writer for The New Yorker, and a professor at Harvard Medical School and the Harvard School of Public Health. He has won the Lewis Thomas Prize for Writing about Science, a MacArthur Fellowship, and two National Magazine Awards. In his work in public health, he is Founder and Chair of Ariadne Labs, a joint center for health systems innovation, and Lifebox, a nonprofit organization making surgery safer globally. He is also chair of Haven, where he was CEO from 2018-2020. He and his wife have three children and live in Newton, Massachusetts.

From The Washington Post's Book World/washingtonpost.com Reviewed by Sarah Halzack Sometimes a deeply complex problem has a deceptively simple answer. That is the underlying message of Atul Gawande's "The Checklist Manifesto," which explains how a short, straightforward medical checklist can greatly reduce the chances of failure in life-or-death situations (and some less serious ones, for that matter). Himself a surgeon, Gawande argues that the medical field has, in some ways, become too sophisticated for its own good. "The volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably," he writes. "Knowledge has both saved us and burdened us." To see how clinicians might do better, Gawande turned to experts in other fields. He studied aviators, chatted with high-stakes investors and visited with an architect working on a skyscraper. A common thread emerged: All of them used some sort of checklist. Curious whether this approach could work in medicine, Gawande hunted for situations where checklists were used in his own field. Even skeptical readers will find the evidence staggering. Gawande found a host of studies that show dramatic drops in death or infection from a certain procedure once a hospital implemented a checklist for doing it right. Marshaling anecdotes and analysis, he implores the medical community to use checklists more widely. He also makes the case for rethinking teamwork and leadership in hospitals. While many surgeons are autonomous rulers of the operating room, he argues that decentralizing power among nurses, anesthesiologists and other physicians increases communication and reduces error. Thoughtfully written and soundly defended, this book calls for medical professionals to improve patient care by adopting a basic, common-sense approach. halzacks@washpost.com
Copyright 2010, The Washington Post. All Rights Reserved.

1. THE PROBLEM OF EXTREME COMPLEXITY

Some time ago I read a case report in the Annals of Thoracic Surgery. It was, in the dry prose of a medical journal article, the story of a nightmare. In a small Austrian town in the Alps, a mother and father had been out on a walk in the woods with their three- year-old daughter. The parents lost sight of the girl for a moment and that was all it took. She fell into an icy fishpond. The parents frantically jumped in after her. But she was lost beneath the surface for thirty minutes before they finally found her on the pond bottom. They pulled her to the surface and got her to the shore. Following instructions from an emergency response team reached on their cell phone, they began cardiopulmonary resuscitation.

Rescue personnel arrived eight minutes later and took the first recordings of the girl’s condition. She was unresponsive. She had no blood pressure or pulse or sign of breathing. Her body temperature was just 66 degrees. Her pupils were dilated and unreactive to light, indicating cessation of brain function. She was gone.

But the emergency technicians continued CPR anyway. A helicopter took her to the nearest hospital, where she was wheeled directly into an operating room, a member of the emergency crew straddling her on the gurney, pumping her chest. A surgical team got her onto a heart- lung bypass machine as rapidly as it could. The surgeon had to cut down through the skin of the child’s right groin and sew one of the desk- size machine’s silicone rubber tubes into her femoral artery to take the blood out of her, then another into her femoral vein to send the blood back. A perfusionist turned the pump on, and as he adjusted the oxygen and temperature and flow through the system, the clear tubing turned maroon with her blood. Only then did they stop the girl’s chest compressions.

Between the transport time and the time it took to plug the machine into her, she had been lifeless for an hour and a half. By the two- hour mark, however, her body temperature had risen almost ten degrees, and her heart began to beat. It was her first organ to come back.

After six hours, the girl’s core reached 98.6 degrees, normal body temperature. The team tried to shift her from the bypass machine to a mechanical ventilator, but the pond water and debris had damaged her lungs too severely for the oxygen pumped in through the breathing tube to reach her blood. So they switched her instead to an artificial- lung system known as ECMO— extracorporeal membrane oxygenation. To do this, the surgeons had to open her chest down the middle with a power saw and sew the lines to and from the portable ECMO unit directly into her aorta and her beating heart.

The ECMO machine now took over. The surgeons removed the heart- lung bypass machine tubing. They repaired the vessels and closed her groin incision. The surgical team moved the girl into intensive care, with her chest still open and covered with sterile plastic foil. Through the day and night, the intensive care unit team worked on suctioning the water and debris from her lungs with a fiberoptic bronchoscope. By the next day, her lungs had recovered sufficiently for the team to switch her from ECMO to a mechanical ventilator, which required taking her back to the operating room to unplug the tubing, repair the holes, and close her chest.

Over the next two days, all the girl’s organs recovered— her liver, her kidneys, her intestines, everything except her brain. A CT scan showed global brain swelling, which is a sign of diffuse damage, but no actual dead zones. So the team escalated the care one step further. It drilled a hole into the girl’s skull, threaded a probe into the brain to monitor the pressure, and kept that pressure tightly controlled through constant adjustments in her fluids and medications. For more than a week, she lay comatose. Then, slowly, she came back to life.

First, her pupils started to react to light. Next, she began to breathe on her own. And, one day, she simply awoke. Two weeks after her accident, she went home. Her right leg and left arm were partially paralyzed. Her speech was thick and slurry. But she underwent extensive outpatient therapy. By age five, she had recovered her faculties completely. Physical and neurological examinations were normal. She was like any little girl again.

What makes this recovery astounding isn’t just the idea that someone could be brought back after two hours in a state that would once have been considered death. It’s also the idea that a group of people in a random hospital could manage to pull off something so enormously complicated. Rescuing a drowning victim is nothing like it looks on television shows, where a few chest compressions and some mouth- to- mouth resuscitation always seem to bring someone with waterlogged lungs and a stilled heart coughing and sputtering back to life. To save this one child, scores of people had to carry out thousands of steps correctly: placing the heart- pump tubing into her without letting in air bubbles; maintaining the sterility of her lines, her open chest, the exposed fluid in her brain; keeping a temperamental battery of machines up and running. The degree of difficulty in any one of these steps is substantial. Then you must add the difficulties of orchestrating them in the right sequence, with nothing dropped, leaving some room for improvisation, but not too much.

For every drowned and pulseless child rescued, there are scores more who don’t make it— and not just because their bodies are too far gone. Machines break down; a team can’t get moving fast enough; someone fails to wash his hands and an infection takes hold. Such cases don’t get written up in the Annals of Thoracic Surgery, but they are the norm, though people may not realize it.

I think we have been fooled about what we can expect from medicine—fooled, one could say, by penicillin. Alexander Fleming’s 1928 discovery held out a beguiling vision of health care and how it would treat illness or injury in the future: a simple pill or injection would be capable of curing not just one condition but perhaps many. Penicillin, after all, seemed to be effective against an astonishing variety of previously untreatable infectious diseases. So why not a similar cure- all for the different kinds of cancer? And why not something equally simple to melt away skin burns or to reverse cardiovascular disease and strokes?

Medicine didn’t turn out this way, though. After a century of incredible discovery, most diseases have proved to be far more particular and difficult to treat. This is true even for the infections doctors once treated with penicillin: not all bacterial strains were susceptible and those that were soon developed resistance. Infections today require highly individualized treatment, sometimes with multiple therapies, based on a given strain’s pattern of anti biotic susceptibility, the condition of the patient, and which organ systems are affected. The model of medicine in the modern age seems less and less like penicillin and more and more like what was required for the girl who nearly drowned. Medicine has become the art of managing extreme complexity— and a test of whether such complexity can, in fact, be humanly mastered.

The ninth edition of the World Health Organization’s international classification of diseases has grown to distinguish more than thirteen thousand different diseases, syndromes, and types of injury— more than thirteen thousand different ways, in other words, that the body can fail. And, for nearly all of them, science has given us things we can do to help. If we cannot cure the disease, then we can usually reduce the harm and misery it causes. But for each condition the steps are different and they are almost never simple. Clinicians now have at their disposal some six thousand drugs and four thousand medical and surgical procedures, each with different requirements, risks, and considerations. It is a lot to get right.

There is a community clinic in Boston’s Kenmore Square affiliated with my hospital. The word clinic makes the place sound tiny, but it’s nothing of the sort. Founded in 1969, and now called Harvard Vanguard, it aimed to provide people with the full range of outpatient medical services they might need over the course of their lives. It has since tried to stick with that plan, but doing so hasn’t been easy. To keep up with the explosive growth in medical capabilities, the clinic has had to build more than twenty facilities and employ some six hundred doctors and a thousand other health professionals covering fifty- nine specialties, many of which did not exist when the clinic first opened. Walking the fifty steps from the fifth- floor elevator to the general surgery department, I pass offices for general internal medicine, endocrinology, genetics, hand surgery, laboratory testing, nephrology, ophthalmology, orthopedics, radiology scheduling, and urology— and that’s just one hallway.

To handle the complexity, we’ve split up the tasks among various specialties. But even divvied up, the work can become overwhelming. In the course of one day on general surgery call at the hospital, for instance, the labor floor asked me to see a twenty-five- year- old woman with mounting right lower abdominal pain, fever, and nausea, which raised concern about appendicitis, but she was pregnant, so getting a CT scan to rule out the possibility posed a risk to the fetus. A gynecological oncologist paged me to the operating room about a woman with an ovarian mass that upon removal appeared to be a metastasis from pancreatic cancer; my colleague wanted me to examine her pancreas and decide whether to biopsy it. A physician at a nearby hospital phoned me to transfer a patient in intensive care with a large cancer that had grown to obstruct her kidneys and bowel and produce bleeding that they were having trouble controlling. Our in...