Do Checklists Lead to Better Decisions?

While life and lives sometimes turn on the basis of big decisions, it’s often the little ones that matter more. Our failure to follow routine, everyday protocols makes the world a more dangerous place for ourselves, and for others.

A few examples…

Nearly 100,000 U.S. patients are killed every year by the failure of doctors and nurses to follow simple instructions. Really. Hospital-acquired infections kill that many people every year, and nearly all those deaths are entirely preventable.

Most airline crashes occur because pilots ignore the rules. Pilot failure to follow protocols is a primary contributing factor to the majority of incidents and accidents.

An important way of attacking these errors is to use checklists.

Support for a checklist approach is provided by a new book, The Checklist Manifesto. In it, the author, Harvard Medical School surgeon Atul Gawande notes, “The volume and complexity of what we know has exceeded our ability to deliver its benefits correctly, safely, or reliably.” Unless, of course, we use checklists.

Dr. Peter Pronovost, a critical care specialist at Johns Hopkins, developed his own operating room checklist, which included some “no brainers” such as wash your hands with soap, put drapes over entire patient, and put sterile dressing over incisions. Without one year of the checklist’s adoption at Johns Hopkins, the post-op infection rate went from 11% to zero.

According to Gawande, in using checklists to improve decisions, we should keep the following guidelines in mind:

  • Include all “stupid but critical” tasks so they’re not overlooked.
  • Make it mandatory for team members to inform others when an item on the list is completed (or not).
  • Empower team members to question superiors about the checklist.
  • Allow for improvisation in unusual circumstances.
  • Thoroughly test-drive the checklist before implementing it.

Gawande notes that checklists aren’t important only for medical decision-making. Engineering, business, technology, safety, and transportation are all industries that would benefit from greater development and use of checklists in everyday decision-making.

As a project manager noted, “Successful checklists detail both the sequence of necessary activities as well as the communication checkpoints to ensure dialog among project participants.”



Checklists work well, except when they don’t.

Checklists have a paradox that makes them of dubious usefulness: The more complex the decision-making, ostensibly the more important the checklist. But the more complex the decision-making, the less likely that a checklist can or should be followed. Checklists can take an impractical amount of time to follow. Driving an automobile is a routine but complex process. Do you keep a checklist in your car for every time you get behind the wheel?

Moreover, by their very nature, complex tasks can pose problems that fall outside the scope of the checklist. The last thing we need to solve unanticipated or complicated problems is rote allegiance to a checklist that is poorly suited to the problem at hand.

Indeed, a problem with many poor decisions is that heuristics are too often followed, with little thought to whether the assumptions behind them still hold true. If we have learned anything from the financial crisis, it is that a model or heuristic is only as good as its assumptions. Assume housing prices are properly valued and likely to continue to increase, and it makes all the sense in the world to be aggressive in making loans. Countrywide and Fannie Mae had all sorts of rules, protocols, and checklists they followed in making catastrophically bad loan decisions.

As for the medical decision-making, as another physician and author, Sandeep Jauhar, noted, advocates of checklists often ignore the unintended consequences. Insurers compensate doctors for ticking off boxes on checklists—like prescribing antibiotics—even when there is no evidence they are warranted. Because this protocol encourages the growth of antibiotic-resistant bacteria, we all are endangered by this checklist-adhering behavior.

We want to think we live in a world where decision-making errors can be easily solved. We can mitigate some decisions by learning more about decision-making errors, but one of the main learning points is that we need a healthier respect for the degree to which we’re susceptible to errors. Checklists provide a false sense of security and an ignorance about when they cause more problems than they solve.


Source: S. Jauhar, “One Thing After Another,” New York Times Book Review (January 24, 2010), p. 7; C. Arnst, “Make a List. Check it Twice,” Bloomberg Business Week (Feburary 22, 2010), pp. 78-79; J. Ross, “The Checklist Manifesto And The Digital Divide,” Forbes (July 27, 2010), downloaded on May 7 from