Checklists in High Stakes Work

Trevor L Taylor, the founder of Fortius Capital, joins the habits of a former Division I athlete to systematic investing, and the checklist may be the plainest expression of that idea: excellence built from repeatable steps rather than memory and talent alone. Checklists are not glamorous. Their record in aviation and medicine shows why they matter anyway. When work is complex and the cost of a missed step is high, even the most experienced people forget things, and a short written list catches errors that skill does not.

The cockpit origin story

The modern story usually begins with an airplane. In a New Yorker article on checklists¹, the surgeon and writer Atul Gawande recounted the Army Air Corps competition for a new long range bomber in which Boeing’s Model 299 had outclassed its rivals. On a demonstration flight the plane climbed, stalled and crashed, killing two of the five crew members, including the pilot. Investigators found nothing mechanically wrong. The aircraft demanded attention to four engines, retractable landing gear, new wing flaps, electric trim tabs and hydraulically controlled propellers, and the pilot, the service’s chief of flight testing, had forgotten to release a new locking mechanism on the controls. A newspaper called it too much airplane for one man to fly.

The response was not more training, since it was hard to imagine more expertise than the pilot already had. Test pilots instead wrote a pilot’s checklist with step by step checks for takeoff, flight, landing and taxiing. With the list in hand, Gawande wrote, pilots flew the Model 299 a total of 1.8 million miles without an accident, and the Army ultimately ordered almost thirteen thousand of the aircraft, which it called the B 17. Checklists became a permanent part of flying, and NASA later funded detailed study of how crews actually use them; a NASA contractor report by Asaf Degani and Earl Wiener² examined the human factors of the normal checklist that airline pilots run on every flight.

The intensive care line infection checklist

Medicine resisted the idea for decades. Physicians, Gawande wrote, were skeptical that a sheet of paper with little boxes would improve care, even though an intensive care patient may need a hundred and seventy eight daily tasks done correctly. In 2001 Peter Pronovost, a critical care specialist at Johns Hopkins Hospital, tried anyway. He did not attempt to cover everything; he designed a checklist to tackle a single problem, infections from central lines, the catheters threaded into large veins.

Reviewing Gawande’s later book for The New York Times³, the reviewer noted that doctors often overlook or omit steps among the many tasks they perform every day, and that the five point checklist introduced at Johns Hopkins virtually eradicated central line infections in its intensive care unit. Pronovost told the Times in a later interview⁴ that his reasoning was simple: hospital infections are not like a disease with no cure, so he set out to standardize what clinicians do before catheterization.

The approach then spread statewide. NPR reported⁵ that Pronovost’s program saved Michigan more than $100 million and 1,500 lives over an 18 month period by teaching intensive care staff to use checklists for routine procedures.

The surgical safety trials

Surgery was the next test. An expert panel convened by the World Health Organization for its Safe Surgery Saves Lives initiative, led by Gawande, produced a single page checklist that takes a few minutes to complete. A study published in the New England Journal of Medicine⁶ tested a 19 item surgical safety checklist meant to improve team communication and consistency of care in eight hospitals in eight cities, from Toronto and London to New Delhi, Manila and Ifakara in Tanzania. The death rate fell from 1.5 percent before the checklist to 0.8 percent afterward, and inpatient complications fell from 11.0 percent to 7.0 percent. The Harvard Gazette summarized⁷ the result as a drop in deaths and complications of more than one third, and reported that the reductions in complications were of equal size in high income and lower income sites.

The World Health Organization⁸ now describes much of its safe surgery work as enabled by the global implementation of the WHO Surgical Safety Checklist. Yet the evidence is not uniform. When Ontario encouraged every hospital to adopt surgical checklists, researchers writing in the same journal⁹ compared more than 100,000 procedures before adoption with a similar number after, across 101 hospitals. The adjusted risk of death was 0.71 percent before and 0.65 percent after, and the rollout was not associated with significant reductions in operative mortality or complications.

What makes a checklist work

The gap between those two results is the most useful lesson in the field. Both studies compared outcomes before and after adoption rather than randomizing hospitals, so neither proves cause on its own. The pilot hospitals had trained teams and close attention from researchers; a policy that encourages adoption across a province may produce lists that are ticked rather than used. Pronovost’s own success came from narrowing the checklist to one problem with a small number of steps, and the aviation tradition Degani and Wiener studied treats a checklist as a designed tool, written for the moments when crews are busiest. A checklist works when the people using it believe in it, when it is short enough to finish and when it targets the errors that skilled people actually make.

The same principles carry into other high stakes decisions. An investor’s due diligence list, a pilot’s before takeoff checks and a surgical team’s pause before the first incision share one purpose: to move a handful of known failure points out of memory and onto paper. That pairs naturally with a premortem, which looks for new ways a plan could fail, and with the record keeping described in training logs and investment journals. Seen this way, a checklist is less a form than a decision, made in calm conditions, about which mistakes a capable team refuses to repeat under pressure.