Comment about the book: “The Checklist Manifesto”

I have enjoyed reading New Yorker and other articles by Atul Gawande and just finished reading his book, “The Checklist Manifesto.” Here is a comment about the section in the book where he is conducting a trial about using a checklist for surgery. From page 142:

“Lastly, the hospitals had to be willing to allow observers to measure their actual rates of complications, deaths, and systems failures in surgical care before and after adopting the checklist…..Most …. have no idea of their current rates”

He then goes on to describe the trial as a success.

Yet, consider the FRACAS process (Failure Reporting And Corrective Action System) as shown below(1).

The steps are to:

  1. Observe failure events
  2. Classify (analyze) events
  3. Propose and institute corrective actions
  4. At all times, measures error rates.

In “The Checklist Manifesto”, a corrective action is proposed – call it a hypothesis – to improve error rates during surgery, without knowing the current error rates and perhaps more importantly, not knowing if the checklist is even the right corrective action. Moreover, as part of the trial, – the before phase – errors were observed, their rates were measured and errors were classified as to their cause. Some of these errors seem to have been corrected during this phase, leading to an improved error rate when the checklist was started. Hence, after the trial, the improvement in the error rate was not due solely to the checklist.

I’m sure that the checklist was responsible for part of the error rate improvement, but the point is that the FRACAS process was performed and it is this process that is the key to improvement. For example, the reduction of the infection rate in central lines by Dr. Pronovost (mentioned in this book) was achieved by conducting FRACAS (although he never used that term). It just so happened that the corrective action chosen was a checklist. 

The use of checklists is often beneficial because checklists reduce the rate of non cognitive errors (slips) and at risk behavior.


  1. CLSI/NCCLS Risk Management Techniques to Identify and Control Laboratory Error Sources. Approved Guideline –Second Edition CLSI/NCCLS document EP18-A2 Wayne, PA: NCCLS; 2009.

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