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In this book, Atul Gawande sets out to solve a problem: the frequent errors that take place at the highest levels of medicine, business, law, or ‘in almost any endeavour requiring mastery of complexity and of large amounts of knowledge’.

For Gawande, the reason for this issue is evident: ‘the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably.’

He illustrates the problem with myriad examples – Intense stories from the frontlines of surgery. Analysis of natural disaster responses, to name a couple.

His suggestion is strikingly simple… It’s a checklist.

Gawande says that it ‘somehow feels beneath us to use a checklist, an embarrassment’. But drawing from best practices in the construction and aviation industries, he shows how a simple idea can generate staggering improvement.

However, the book goes much deeper. It’s not simply enough to come up with a checklist. For a basic solution to work there must be some serious work and thought put in. With that in mind, here are my major takeaways:


At WABT communication is what we do. So, this is an obvious choice. But also, an important one.

An idea running through the book is the decline of the ‘master builder’. A term you may be familiar with from the construction industry or indeed The Lego Movie. This is someone who has complete knowledge of every trade on a job. Someone who’s expertise is deferred to in times of uncertainty. The Checklist Manifesto argues that, in many industries, expertise is now so specific to individual tasks that it is impossible for someone to have mastery over them all.

Whilst observing a building crew working on a new skyscraper, Gawande saw them run into a major issue. One where they couldn’t be sure of the cause. And accordingly, one a checklist of tasks couldn’t account for. What was the crew’s play? They used a ‘submittal schedule’. Literally a checklist for communication. Who should talk to who by what date.

‘In the face of the unknown… the builders trusted in the power of communication.’ They knew that ‘In the absence of a master builder… autonomy is a disaster. It only produces a cacophony of incompatible decisions and overlooked errors.’ The experts in each trade could make their judgements. But ‘they had to do so as part of a team that took one another’s concerns into account, discussed unplanned developments and agreed on a way forward’.


It should go without saying – communication without clarity is worthless. This is a problem Atul Gawande ran into when he first attempted to use his surgery checklist.

Once the operation prep was finished, the patient was about to be administered anaesthesia. Gawande remembered the checklist, only to find that one of the nurses had already completed it. This was wrong. It was supposed to be a verbal checklist, completed as a team. The nurse’s defence was solid: ‘” Where does it say that?” she asked. I looked again. She was right. It didn’t say that anywhere.’

Almost as bad – ‘some of the checks were ambiguous’. And, ‘after a few minutes of puzzling our way through the list, everyone was becoming exasperated. Even the patient started shifting around on the table.’


We spend a lot of time and energy on WHAT we want to communicate. We have to spend just as much on HOW we will communicate it.


As well as being clear and instructive, communications must hold attention. They must make people care.

In the book, Boeing’s Daniel Boorman says that poor checklists ‘treat the people using the tools as dumb and try to spell out every single step. They turn people’s brains off rather than turn them on.’

Lack of engagement results in lack of positive action. Meaning change is greatly delayed. The book details a medical study that followed the aftermath of nine major treatment discoveries. It found that ‘on average… it took doctors seventeen years to adopt new treatments for at least half of American patients.’

For Gawande, this is NOT due to ‘laziness or unwillingness’. Often, it is down to ‘the necessary knowledge not being translated into a simple, usable, and systematic form.’ He then goes on to say, ‘If the only thing people did in aviation was issue dense, pages-long bulletins for every new finding that might affect the safe operation of airplanes… The information would be unmanageable.’

There is a line in this book where the author describes the purpose of his checklists. I think it can apply widely to communications in general - 'Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is.'


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