Are you using enough checklists? It feels like the world is getting increasingly complicated, and I’m sure we’ve all experimented with various memory aides to try to remember everything we have to do. These range from the humble checklist to the mighty online planning tool with hyperlinked entries. For most of us, though, I suspect it’s hard to know what we’re doing right.

Gawande, a surgeon himself, is firmly convinced by the virtue of the checklist, and in his hands it becomes a powerful and thought-provoking tool to confront complexity. He begins by pointing out there are two reasons we fail: ignorance, if we don’t know something, and ineptitude, if we know how to do something and do it wrong. It is the second problem that is the most serious in the modern world, he argues, and checklists can make a dramatic difference.

There are approximately 150,000 deaths following surgery in the US, about 3x as many as deaths from car accidents, and so he’s got a point. If checklists can reduce even a small percentage of errors in surgery, it could make an enormous difference. Fortunately, Gawande has a number of stories of astonishing success from checklist adoption. When Johns Hopkins introduced a checklist for central line insertions, for example, infection rates dropped from 11% to zero; when Michigan did, it probably saved over 1,500 lives in 18 months. The results are much the same in fields as diverse as aviation or skyscraper construction.

He does caution readers not to overreach, however. Checklists longer than 5 to 9 items long become cumbersome, and people start ignoring them. Good lists therefore focus on the steps that make the biggest difference, and the ones likely to be forgotten. Too long, and they stop being effective. They also need to be carefully tested: much of the book is devoted to failed attempts at introducing checklists, as people have a tendency to ignore or fail to follow the list unless it is designed well.

The book’s a quick and easy read, but the idea is extremely powerful. Gawande talks about his own initial reluctance to adopt checklists, seeing himself as above them, and his more recent reversal of opinion. When he asked surgeons about the value of a checklist, 20% said it did not improve safety. When asked if they would want it used in surgery on them, however, 93% agreed. I suspect we could all benefit from a bit more humility and a few more lists.

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