The Checklist Manifesto

We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And, with it, they have indeed accomplished extraordinary things. Nonetheless, that know-how is often unmanageable.

Complexity overwhelms even experts. In fields like medicine, aviation, and finance, professionals deal with an ever-increasing volume of knowledge and intricate procedures. This complexity leads to errors, oversights, and potentially catastrophic outcomes. Checklists provide a systematic approach to managing this complexity, ensuring that critical steps are not missed and that teams can effectively coordinate their efforts.

• Examples of complex fields benefiting from checklists:

  • Surgery

  • Aviation

  • Construction

  • Finance

  • Emergency response

Checklists as cognitive aids. By externalizing memory and decision-making processes, checklists free up mental resources for higher-level thinking and problem-solving. They act as a safety net, catching simple mistakes that even highly trained professionals can make under pressure or during routine tasks.

The volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.

Expertise is not infallible. Despite years of training and experience, experts in various fields are still prone to human error. Checklists serve as a powerful tool to complement expertise, ensuring that even the most basic yet critical steps are not overlooked in the midst of complex procedures.

Checklists catch the "stupid stuff". They are particularly effective in preventing errors that result from:

• Memory lapses

• Distractions

• Fatigue

• Complacency

• Time pressure

Real-world impact. In medicine, for example, implementing simple checklists has led to significant reductions in surgical infections, complications, and deaths. Similar improvements have been observed in aviation, construction, and financial investing when checklists are consistently used.

Good checklists, on the other hand, are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything—a checklist cannot fly a plane.

Characteristics of good checklists:

• Brief and focused on "killer items"

• Clear and simple language

• Practical for real-world use

• Tested and refined through iteration

Checklist design process. Creating an effective checklist involves careful consideration of the most critical steps in a process. It requires input from experts in the field and multiple rounds of testing and refinement. The goal is to create a tool that enhances performance without becoming a burden or distraction.

Types of checklists. Two main types are identified:

1. READ-DO: Steps are performed as they are read

2. DO-CONFIRM: Tasks are completed from memory, then verified against the checklist

The choice between these types depends on the specific context and needs of the situation.

They had determined that the most promising thing to do was just to have people stop and talk through the case together—to be ready as a team to identify and address each patient's unique, potentially critical dangers.

Fostering team communication. Checklists serve as a framework for structured communication among team members. They ensure that critical information is shared and that everyone has a clear understanding of the task at hand, potential risks, and individual responsibilities.

Breaking down hierarchies. By requiring input from all team members, checklists can help overcome traditional hierarchies that may inhibit open communication. This is particularly important in fields like medicine, where junior staff members may hesitate to speak up about potential issues.

Checklist as a team-building tool:

• Encourages introductions and role clarity

• Provides designated pause points for discussion

• Promotes a shared mental model of the task

• Empowers all team members to voice concerns

We don't like checklists. They can be painstaking. They're not much fun. But I don't think the issue here is mere laziness. There's something deeper, more visceral going on when people walk away not only from saving lives but from making money.

Professional pride as a barrier. Many experts resist checklists because they view them as an insult to their skills and experience. There's a prevailing belief that true expertise means being able to handle complex situations without external aids.

Autonomy vs. discipline. The use of checklists requires a shift from valuing individual autonomy to embracing disciplined teamwork. This can be particularly challenging in professions that have traditionally emphasized personal judgment and decision-making.

Overcoming resistance:

• Demonstrate the effectiveness of checklists through data and case studies

• Involve respected professionals in checklist development and implementation

• Frame checklists as tools that enhance rather than replace expertise

• Cultivate a culture that values both individual skill and systematic approaches

After our London meeting, we did more small-scale testing—just one case at a time. We had a team in London try the draft checklist and give us suggestions, then a team in Hong Kong. With each successive round, the checklist got better.

Aviation's success story. The dramatic improvement in aviation safety over the past decades can be largely attributed to the systematic use of checklists. This success provides a compelling model for other high-risk industries.

Transferring lessons learned. The principles that made checklists effective in aviation can be adapted to other fields:

• Identifying critical steps and potential failure points

• Creating clear, concise checklist items

• Regular review and updating of checklists

• Integration of checklists into standard operating procedures

• Fostering a culture of discipline and teamwork

Beyond aviation. Fields that have successfully implemented checklists include:

• Medicine (surgical safety, ICU care)

• Construction (building safety, project management)

• Finance (investment decision-making)

• Emergency response (disaster management)

This was what was unusual. This is what it means to be a hero in the modern era. These are the rare qualities that we must understand are needed in the larger world.

Redefining heroism. In complex, high-stakes environments, the true hero is not the lone expert who relies solely on individual skill, but the professional who embraces tools and teamwork to achieve the best possible outcomes.

Characteristics of the modern hero:

• Humility to acknowledge personal limitations

• Discipline to follow systematic approaches

• Commitment to continuous improvement

• Willingness to communicate and collaborate effectively

Cultural shift required. Embracing this new model of heroism requires a significant shift in professional cultures that have long valued individual autonomy and expertise above all else. It involves recognizing that in many modern contexts, success is a team effort supported by robust systems and tools.

The final results showed that the rate of major complications for surgical patients in all eight hospitals fell by 36 percent after introduction of the checklist. Deaths fell 47 percent.

Measurable impact. The implementation of checklists has led to dramatic improvements in outcomes across various fields:

• Surgery: Reduction in complications and deaths

• Aviation: Fewer accidents and improved safety records

• Construction: Decreased building failures and improved project management

• Finance: Better investment decisions and risk management

Beyond error prevention. Checklists not only reduce errors but can also:

• Improve efficiency and productivity

• Enhance team coordination

• Increase consistency in complex processes

• Provide a framework for continuous improvement

Case studies. Examples of successful checklist implementations include:

• WHO Surgical Safety Checklist

• Investment checklists used by value investors

• Construction project management checklists

• Emergency response protocols in disaster management

What experts like Dan Boorman have recognized is that the reason for the delay is not usually laziness or unwillingness. The reason is more often that the necessary knowledge has not been translated into a simple, usable, and systematic form.

Leadership commitment. Successful implementation of checklists requires strong support from organizational leaders. They must champion the use of checklists and model their adoption to overcome resistance.

Cultural transformation steps:

1. Educate staff on the benefits and rationale behind checklists

2. Involve key stakeholders in checklist development and refinement

3. Provide training and support for checklist use

4. Monitor and celebrate successes

5. Continuously improve checklists based on feedback and results

Overcoming implementation challenges:

• Address concerns about increased workload or time requirements

• Demonstrate how checklists enhance rather than replace professional judgment

• Customize checklists to fit specific organizational needs and cultures

• Integrate checklist use into existing workflows and systems

By fostering a culture that values systematic approaches and teamwork, organizations can harness the full potential of checklists to improve outcomes, reduce errors, and manage complexity in high-stakes environments.