Tag Archives: The Checklist Manifesto

Let’s Call It The “We Can’t Keep Up” Syndrome

Here’s what I’m trying to say:  we don’t yet know how to do everything we are trying to do.  And that can be a real problem.

The totals are now beyond what most of us could have only imagined — and feared.  The total number of gallons of oil that have spewed into the Gulf from the BP disaster has probably surpassed 200 million gallons  (The figures are not precise — I did the math from this web site).  This is 18x the number of gallons from the Exxon Valdez disaster.  It seems like such a long time ago that Tony Hayward, and Haley Barbour, and others, stated that the Gulf was a big ocean and would easily disperse the oil harmlessly.  They were, sadly, wrong.  We have learned that lesson the hard way.

And the new iPhone is running into turmoil that is building day after day.  Partly because, in my opinion, AT&T was not yet ready to provide the infrastructure for all that technology.  It was too much innovation and implementation too soon.  The capacity to execute can not quite keep up with the needs of the era, with ever more challenging products and projects.  Consider this excerpt of AT&T CTO: ‘We will move heaven and Earth’ to improve our network by Anthony Ha (full article here):

When VentureBeat Editor in Chief Matt Marshall got a chance to ask AT&T Chief Technology Officer John Donovan a few questions on-stage, he asked what kinds of issues are holding back network quality. It’s a little bit of everything, Donovan replied. With a flood of new chipsets, phones, and applications, the traditional device testing and rollout methods have “broken down.” In addition, AT&T recently faced a shortage of the components needed to improve its network.

“I’ll tell you the things it’s not been,” Donovan said. “It’s not been capital, it’s not been conviction and commitment.” AT&T “will move heaven and Earth” to meet its customers’ growing data needs, he said.

I have blogged before (a few times) about the formulation from Atul Gawande’s The Checklist Manifesto, re. the two great problems:  ignorance and ineptitude.  Here’s the key quote:

We have just two reasons that we may fail.
The first is ignorance – we may err because science has given us only a partial understanding of the world and how it works.  There are skyscrapers we do not yet know how to build, snowstorms we cannot predict, heart attacks we still haven’t learned how to stop. The second type of failure the philosophers call ineptitude – because in these instances the knowledge exists, yet we fail to apply it correctly  This is the skyscraper that is built wrong and collapses, the snowstorm whose signs the meteorologist just plain missed, the stab wound from a weapon the doctors forgot to ask about.
For nearly all of history, people’s lives have been governed primarily by ignorance.

But there is a third problem, one that does not quite have a name yet.  Let’s call it the “we can’t keep up” syndrome.  Maybe it is a subset of one of the two by Gawande.  But it presents a unique challenge to the modern business environment.

It is not entirely new.  In the early days of television, there were television set makers dependent on television networks dependent on television makers.  It was a circle of interdependency, a complex set of interconnections, with officially disconnected but very interdependent companies needing every company in the mix to keep up.  And keeping up was tough.

Just in the last year, television stations have switched to HD, needing the cable channels to provide slots for their new HD channels, with the cable channels needing the stations to broadcast in HD.  Everything is so interconnected, interdependent.  Everyone has to succeed for anyone to succeed – one has to succeed for all to possibly succeed.

And then, the ripple effects.  There is now no doubt that people working in companies with much better safety records than BP are paying the price for BP’s failures.  Jobs are leaving the Gulf for other oceans across the globe.  The moratorium, which many object to (but – can you imagine if a second well had this kind of disaster right now?) means that costly equipment has to go where there is work.  And then the equipment will be run by a new set of workers.

But here is the deal.  Companies, entire industries, need to learn, adapt, innovate as they go…and it is tough to keep up.

Maybe the problem is not incompetence.  Maybe the problem is not ineptitude (though there were serious mistakes made).  Maybe it is simply that we are in a perpetual growth/innovation/need-to-get-it-right era, and there will always be a need for version 2.0 and 2.8 and 7.0 in nearly every arena.

If all it means is that I have to wait for the next software update on my iPhone, I’m ok with that.  But if it destroys the environment on the Gulf Coast for hundreds of miles, then it becomes a much more serious matter.

What Went Wrong? – A Question Worth Asking (wisdom from James Bagian)

James Bagian

Slate.com has a terrific interview up with James Bagian.  It is in their The Wrong Stuff: What It Means To Make Mistakes series.  This interview is titled: Risky Business: James Bagian—NASA astronaut turned patient safety expert—on Being Wrong by Kathryn Schulz.

Mr. Bagian was scheduled to be on the Challenger mission, and his crew was switched out.  He has studied failures/mistakes for many years.  His current job is director of the Veteran Administration’s National Center for Patient Safety. The entire interview its absolutely worth reading, but here is one brief excerpt:

You were part of the team that investigated the Challenger accident. Were you satisfied with how that investigation was handled?

Overall I didn’t have big problems with it. But one thing that was deliberately buried was what happened to the crew. I did that part of the investigation, and there was tremendous political pressure not to tell anyone what happened—not even the other people in the crew office. They didn’t learn for months, which was totally inappropriate. They wouldn’t even let us put in checklists about what to do in the case of a breakup similar to Challenger. (emphasis added). There’s ways you could probably survive it, but politically we weren’t allowed to discuss that for years, which to me is total hogwash. There are still many people that don’t understand that the crew of the Challenger didn’t die until they hit the water. They were all strapped into their seats in a basically intact crew module; their hearts were still beating when they hit the water. People think they were blown to smithereens, but that’s not what happened. And the problem with that is the same one we were talking about with regard to medicine: if you don’t learn what you can from a tragedy, you can’t mitigate that risk in the future.

The entire interview, without ever mentioning Atul Gawande’s The Checklist Manifesto, is an argument for such checklists – for multiple checks throughout the system – to reduce mistakes.

Studying what went wrong is truly worth the time…

“We Don’t Know It” & “We Blow It” – Two Paths to Potential Disaster

I mentioned to a group this week that I think The Checklist Manifesto by Atul Gawande is the most important book I have ever presented.  Not necessarily the best book – but the most important book.  I think about its principles, such as that our age is an age of great complexity, with nearly every news story I read.  I have blogged about it so often that my readers must be thinking, “Oh no – not another Gawande blog post…”

But today, as I was going thorugh the concepts  of the book yet again, these two simple phrases flew out of my mouth.

“We don’t know it”
We blow it.”

All mistakes that we make flow from one of these.  Here are the relevant quotes from Gawande’s book (emphasis added):

We have just two reasons that we may fail.
The first is ignorance – we may err because science has given us only a partial understanding of the world and how it works.  There are skyscrapers we do not yet know how to build, snowstorms we cannot predict, heart attacks we still haven’t learned how to stop. The second type of failure the philosophers call ineptitude – because in these instances the knowledge exists, yet we fail to apply it correctly  This is the skyscraper that is built wrong and collapses, the snowstorm whose signs the meteorologist just plain missed, the stab wound from a weapon the doctors forgot to ask about.
For nearly all of history, people’s lives have been governed primarily by ignorance.

Failures of ignorance we can forgive.  If the knowledge of the best thing to do in a given situation does not exist, we are happy to have people simply make their best effort.  But if the knowledge exists and is not applied correctly, it is difficult not to be infuriated.

In other words:
“We don’t know it” (our problem with ignorance)
“We blow it.” (our problem with ineptitude).

We don’t know it.
We blow it.

Solve these two, and we will have a much less troublesome world.


To purchase my synopsis of The Checklist Manifesto, with handout + audio, go to our companion web site, 15minutebusinessbooks.com.

What Did We Miss? What Did We Forget? – Dr. Gawande Keeps Reminding Us Of Our Fallibility

Things were simpler when we knew less.

As I think about the books I have read, and especially the books I have presented, I always ask myself:  “what is the best book of the whole lot?”  I have presented synopses of a minimum of one business book a month for over 12 years.  There are some really good books:  books that have important lessons and principles to teach us, books that are good-to-great reads.  (By the way, I’m back to my old favorite as my “favorite” book of the 12+ years:  The Creative Habit by Twyla Tharp).  But, I am increasingly  convinced that the most important book I have read in this span is The Checklist Manifesto by Atul Gawande.

On the New Yorker website, you can read Dr. Gawande’s commencement speech which he delivered to Stanford’s School of Medicine: The Velluvial Matrix.  It includes numerous reminders of the core truth from The Checklist Manifesto.  Here’s the key paragraph from the book:

Every day there is more and more to manage and get right and learn.  And defeat under conditions of complexity occurs far more often despite great effort rather than from a lack of it.
It is not clear how we could produce substantially more expertise than we already have.  Yet our failures remain frequent.  They persist despite remarkable individual ability.
(our) know-how is often unmanageable.  Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields – from medicine to finance, business to government.  And the reason is increasingly evident:  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.
That means we need a different strategy for overcoming failure…

In this speech, Dr. Gawande tells the story of a many who had his spleen removed.  The doctors who removed it did a great, remarkable job of saving his life under difficult circumstances.  A medical team rallied, pulled their diverse and comprehensive knowledge together, and performed a series of life-saving procedures successfully that saved the man’s life.  But…  they forgot something – something rather important..

Here’s the story:

Earlier this year, I received a letter from a patient named Duane Smith. He was a thirty-four-year-old assistant grocery-store manager when he had a terrible head-on car collision that left him with a broken leg, a broken pelvis, and a broken arm, two collapsed lungs, and uncontrolled internal bleeding. The members of his hospital’s trauma team went swiftly into action. They stabilized his fractured leg and pelvis. They put tubes in both sides of his chest to reëxpand his lungs. They gave him blood and got him to an operating room fast enough to remove the ruptured spleen that was the source of his bleeding. He required intensive care and three weeks of hospital recovery to get through all this. The clinicians did almost every single thing right. Smith told me that to this day he remains deeply grateful to the people who saved him.

But they missed one small step. They forgot to give him the vaccines that every patient who has his spleen removed requires, vaccines against three bacteria that the spleen usually fights off. Maybe the surgeons thought the critical-care doctors were going to give the vaccines, and maybe the critical-care doctors thought the primary-care physician was going to give them, and maybe the primary-care physician thought the surgeons already had. Or maybe they all forgot. Whatever the case, two years later, Duane Smith was on a beach vacation when he picked up an ordinary strep infection. Because he hadn’t had those vaccines, the infection spread rapidly throughout his body. He survived—but it cost him all his fingers and all his toes. It was, as he summed it up in his note, the worst vacation ever.

In his work, his book, this speech, Dr. Gawande reveals the crisis of the era:

“What did we miss?  What did we forget?”

Because, the more we know, the more we have to “remember,” the greater the chance that we will not remember it all. And, thus, warning signs are missed.  And preventative steps are not taken.  (anybody heard of the Gulf Oil disaster?!)

The Checklist Manifesto is Dr. Gawande’s suggested solution — for medicine, for construction, for aviation…for every conceivable kind of job that requires mastering an array of complex elements.  Which is, by the way, every job!

So, here are two questions to add to your daily routine:

“What am I missing?  What am I forgetting?”


You can purchase my synopsis of The Checklist Manifesto, with audio + handout, at our companion web site, 15minutebusinessbooks.com.

Gawande – Meet the Gulf Oil Disaster

Let’s put it in simple terms.  The more complex the task, the more details that all of the people involved have to get just right, the greater the likelihood that something is going to be missed.  And when that something is missed, something might go wrong – horribly wrong.

I have a simple suggestion.  Everyone involved in deep water drilling needs to have a mandatory session with Atul Gawande.  And then they need to take their best minds and develop their own checklists – and then follow them as though their lives depend on it.  Because they do.  (maybe they already have such checklists — but they certainly did not follow them!).

We now know enough about the Gulf Oil disaster to know that there were multiple warning signs.  They were in such a hurry to get through – to the next assignment, the next drilling location – to get the oil out from beneath the floor of the ocean (way beneath the floor of the ocean), that they simply skipped the warning signs and ignored what they knew they should not ignore.  They needed a drill sergeant nurse, a team committed to the checklist, so that someone could yell, loudly and clearly, “we’ve missed a step…” – so they could stop and get it right.

Here’s how I described Gawande’s book in my synopsis handout:

The world is ever more complex.  We have too much to learn/remember/do.  “This is more airplane than any one person can fly.”  The pressures of the moment, and the built-up pressures of our schedules, means that we need a tool to remember the important tasks – the tasks that if we forget them or do them poorly, it could spell disaster.
We need a checklist.

Here are a couple of quotes from his book, The Checklist Manifesto:

We don’t study routine failures in medicine, teaching, law, government programs, the financial industry, or elsewhere.  We don’t look for the patterns of our recurrent mistakes or devise and refine potential solutions for them…  But we could…
When we look closely, we recognize the same balls being dropped over and over, even by those of great ability and determination.  We know the patterns.  We see the costs.  It’s time to try something else.
Try a checklist.

I have yet to go through a week in surgery without the checklist’s leading us to catch something we would have missed.

The last chapter in the book is called “The Save.” One item on the surgical checklist is to have some pints of blood in the operating room – “just in case.”  This particular operation was supposed to result in “little loss of blood.”  Gawande described how he thought the checklist would help so many doctors, but as for Gawande himself – well, he was good enough, careful enough, that he did not truly need the checklist.  But, he signed on so as not to be a hypocrite.  One of the nurses reported, as the checklist was read in the operating room (operating theater, as it is called), that she had obtained the required pints of blood.  And then…  a bad cut. Blood gushed.  By the end of the entire ordeal, more than two dozen pints of blood had been needed.  The patient lived.  But the initial pints in the room were absolutely critical for the patient’s survival.  The checklist had saved not only the day, but it had saved one precious human life.

I keep thinking of the complexity of our world.  Slate.com has this article up today: Fracking, Oil Sands, and Deep-Water Drilling:  The dangerous new era of “extreme energy, by Daniel Gross.  It describes the complexity, the difficulty, of the tasks we are tackling today to get oil out from deep under the ocean.

Here’s what I think.  The more complex the task, the more critical it is that we have “stop and think” moments – checklists — to avoid the kind of disaster that is continuing to unfold before our eyes.


In this post, I am not weighing in on whether or not we should tackle such dangerous approaches to begin with.  But if we are tackling them, we need to do so with far more care, far more caution – with some very well-designed checklists.

I’ve Been Thinking About Ethical Responsibilities…

Do not, under any circumstances, tell a lie – of either commission or omission.  Do not stretch the truth, exaggerate, or make ___ up to get out of trouble or make yourself look good…
Do not attempt to project different images depending on whom you’re with.  People can spot inauthenticity…  Show up as yourself consistently.  Unless, of course, you are a jackass.

Susan Scott, Fierce Leadership:  A Bold Alternative to the Worst “Best” Practices of Business Today


I’ve been thinking about ethical responsibilities…

You remember ethics don’t you: the discipline dealing with what is good and bad and with moral duty and obligation. — Moral duty and obligation.  Duty…obligation. In other words this is important stuff here.

First, let me state the obvious. To put it in terms well known from the Bible, “all have sinned, and fall short…”  Including me.  And, I say with confidence but no mean-spirited intent, including you.  So, yes, we all have some work to do in this part of our lives.

But it seems to me that falling short has hit epidemic proportions these days.  I don’t know where to put the blame.  Is it the argument culture that Deborah Tannen saw coming?  (see this earlier post here).  Is it exacerbated by the constant spin required on today’s cable news, which flows from this argument culture mentality?  (see my partly tongue-in-cheek Campbell Brown for CEO! here).  Is it our lawyer-laden era, in which if anyone with any power admits fault, then the liability becomes too great?

Or is it a true, genuine, really, really alarming decline in ethical standards?

I don’t know.

But this is what I think I do know.  We have more and more mistakes being made (from the mining disaster to the Toyota problems to the oil rig disaster) where there seems to be a pattern emerging:

• a serious problem occurs;
• part of the cause of the problem is some form of negligence;
• evidence surfaces that warnings were given, but not adequately heeded;
• and then when the full disaster hits, there is some form of denial and shift of blame  (“it’s not my fault!”)

In The Checklist Manifesto, Atul Gawande describes how for most of human history, most big problems were issues of ignorance.  We really did not know what caused disease, we really did not know how to successfully treat a heart attack.  But the pendulum has now swung to the other problem:  human ineptitude is now a bigger problem than human ignorance.  We know more – we just don’t deliver on what we know.  And, as Gawande states:

Failures of ignorance we can forgive.  If the knowledge of the best thing to do in a given situation does not exist, we are happy to have people simply make their best effort.  But if the knowledge exists and is not applied correctly, it is difficult not to be infuriated.

In the latest illustration of this problem, we have a lack of transparency by BP.  They have a genuine, whopping disaster on their hands. The ripple effects are massive, from lives lost, to jobs lost, to the environment damaged, possibly on a massive scale.  But as we follow the BP response, we see the pattern I described above, and during the aftermath we discover that it has taken a lot of pressure – a lot of pressure! – to even get video released of the oil leak for scientists to study.

We all, of course, could give many more examples – from plagiarism by famous authors (there are substantial new plagiarism discoveries regarding now quite discredited author Gerald Posner) to failings of elected officials in categories too numerous to enumerate.

But it really does boil down to this:  our ethical responsibilities are not being treated responsibly.

I’ve grown fond of this phrase:  “you get what you pay attention to.” I think it’s time for companies, and organizations, and elected officials – really, all of us – to pay a lot more attention to our ethical responsibilities.