Book Review: The Checklist Manifesto, by Atul Gawande

One of my personal goals for 2014 is to read a new book every couple of weeks. This is the second book I’ve read this year. The Checklist Manifesto: How to Get Things Right, by Atul Gawande.

Why did I read this?

I read this because I first read Atul Gawande’s article The New Yorker, titled simply The Checklist. The article was surprisingly captivating, so when I found out that Gawande had expanded the article into a full book, I had to read it.

Summary

The Checklist Manifesto is subtitled “How to get things right,” which is  a good summation of the book all by itself. It examines scenarios that are prone to human error, even when those humans are experts at the top of their fields, and how the simple use of a checklist can greatly reduce the error in those situations.

Drawing on examples from aviation, construction, medicine (the author is a surgeon “in real life”), investment banking, and other fields, Gawande shows how checklists have been used to eliminate error.

He describes being recruited by the World Health Organization (WHO) to come up with a plan to improve surgical outcomes worldwide. They decide to experiment with a checklist, asking surgeons in some hospitals to use a pre-surgery checklist in their operating rooms. After Dr. Gawande tries using the checklist himself in his own practice, he finds it cumbersome, confusing, and impractical. He takes a trip to Seattle, where he visits with Daniel Boorman, a Boeing technical fellow, who is responsible for the creation of checklists used by pilots flying Boeing’s airliners.

(Checklists as a tool for professional discipline were born from aviation, even from Boeing: In 1935, a pilot demonstrating Boeing’s newly designed bomber to the Army Air Corps crashed on takeoff, killing himself and two others. He crashed because he had forgotten to release a lock on the airplane’s elevator and rudder controls. The airplane was dismissed as “too much plane for one man to fly,” and the military nearly ended the project. Test pilots, however, thought the airplane was marvelous, and worked together to solve the “too much plane” problem. Their solution was to create a simple set of checklists: One for before takeoff, one for flight, one for approach, and one for landing. With checklists in hand, the test pilots then flew the airplane more than 1.8 Million miles without a single accident. The army ordered 13,000 airplanes, and dubbed it the B-17, now one of the most celebrated bombers in military aviation history.)

Boorman teaches Gawande some of the important things Boeing has learned about checklists: They should use natural breaks in the workflow. They should be relatively short (5-9 items). They should be printed in black & white in a sans-serif font….And more. Boorman then takes Gawande into a hyper-realistic flight simulator, helps him taxi the airplane to a runway and take off, all using the same checklists that pilots use. Then, as their flight ascends through 20,000 feet, a warning light comes on in the cockpit. Gawande’s airplane has a door that appears to not be latched properly. This situation can be deadly (In 1989, this exact situation led to an “explosive decompression” of a United Airlines 747, killing 9 passengers). Gawande, remembering his few minutes of pre-flight training, grabs an emergency procedures book, turns quickly to the checklist for the DOOR FWD CARGO warning light, and follows it. Their simulation flight is able to land safely.

(As an aside, I’m totally jealous that Gawande got to “fly” a full motion 777 simulator. I would LOVE to do that.)

Gawande takes his newfound understanding back to the WHO, where they redesign their surgical checklists following Boeing’s principles, and run a test in 8 hospitals around the world. The results are astounding. They achieve double-digit percentage reductions in complications, infections, and other scary surgical by-products, including death. By his calculations, during the three-month trial in 8 hospitals, the checklists prevented 27 unnecessary deaths.

In the end, Gawande describes an incident in his own operating room where, by his own description, he tore a patient’s vena cava (the largest vein in your body, which bring blood from most of your lower half to your heart). The bleeding was, in Dr. Gawande’s own words, “terrifying.” In seconds, he had opened the patient’s abdomen and chest completely, and was holding his heart in his hands, pumping blood through it while another doctor put pressure on the torn vein. The patient was losing blood a rate measurable in gallons.

One of the items on the surgeon’s pre-incision checklist is to discuss with the operating room team the possible blood loss in the operation. Then, the head nurse calls and confirms that the hospital’s blood bank has enough blood ready to use to cover the worst case scenario (the blood bank is supposed to do this already, without the nurse having to make the call). Gawande’s team had followed the checklist. When the nurse called the blood bank, it was discovered that the blood for this operation was not ready, so the operation was held up a few minutes while the blood bank prepared.

Now, Gawande has the patient’s heart in his hands, and can feel it emptying out like a deflating balloon, and in seconds, the blood from the blood bank is being transfused into the patient. The blood that wouldn’t have been ready to use if the team hadn’t followed its checklist.

By the time the vein is repaired and the patient’s heart is beating on its  own again, 30 “units” of blood have been transfused (keep this in mind: an adult body holds about 10 units: This patient bled 3 times his own blood volume). The patient lived, and while there were some side effects of the incident, recovered. Dr. Gawande is 100% certain that without the checklist, the patient would have died on the operating table while they waited precious minutes for the blood bank.

What did I think?

It’s hard to imagine a subject duller than checklists. Yet Gawande is a good writer, and fills the book with powerful narratives. Whether recounting incredible medical recoveries, telling what happened in the cockpit of USAir 1493 as it crash-landed in the Hudson river, or describing the qualities of a well-written checklist, his writing is engaging.

As for the book’s subtitle “How to get things right,” we’re given a few insights into how to get things right in our own worlds, like the difference between simple, complicated, and complex tasks, and how checklists can (and can’t) help with each (For example, there will be no checklist for raising a child, but there can be one for making sure a child has good nutrition), but I would have liked a little more of the “how to” material.

Ultimately, I was surprised that I found The Checklist Manifesto hard to put down, and when I turned the last page, I wanted to read more.

Would I recommend it?

Here’s the test: Go read The Checklist. If you enjoy it, you’ll like The Checklist Manifesto. I did.

Book Review: The Power of Habit, Charles Duhigg

One of my personal goals for 2014 is to read a new book every couple of weeks. I started the year off with Charles Duhigg’s The Power of Habit.

The Power of Habit, by Charles Duhigg

Why did I read this?

I first became interesting in this book after hearing two interviews with the author. The first from NPR, and the second from Ramit Sethi. I think psychology is interesting, even more if I can use an understanding of that psychology to help reach my goals, or help others reach theirs.

What did I think?

The Power of Habit is easy reading. It is largely anecdotal, sharing its message in narrative form. When the book tells of someone who acquired, broke, or changed a habit, it tells their story. When it talks of the psychology/neurology behind the habit, it tells the story of how the science was conducted and the conclusions discovered. When it speaks of powerful organizational and social change that can happen because of habits, it tells stories of companies, churches, and nations who have done exactly that. Some of the stories include:

  • How a woman gave up smoking and drinking in one day
  • How another woman slowly acquired a multi-million dollar gambling addiction over the course of years, encouraged by a casino that understood the psychology of her habits far better than she did
  • How an alcoholic learned about the principles of habit formation and used them to start the largest organization dedicated to positive personal change in the world
  • How Alcoa aluminum multiplied its profits 5x by focusing on an organizational habit that had nothing to do with sales, margins, shareholder value, or even profit
  • How Michael Phelps set a world record in the 200-meter butterfly at the 2008 Olympics despite an “equipment malfunction” which left him blind for most of the race
  • How the habits of individuals and groups contributed to the Montgomery bus boycott, and ultimately the civil rights movement of the 1960s
  • How Target knows what products to advertise to you before you even know you want them
  • …And a lot more

In my opinion, the book started strong, and then lost momentum towards the end. I think, though, that it’s because the ideas of personal habit formation and change strike close to home for me – they are things I can do. I don’t run a large organization or have any major social cause to champion, so the sections on organizational and social habits were a little less interesting (though I did find Alcoa’s story, and Target’s, to be absolutely fascinating). The book concludes with an appendix that teaches an actionable system for habit change, and walks through how the author discovered, diagnosed, analyzed, and changed an afternoon snacking habit that was causing him to gain weight.

Would I recommend it?

If you’re interested in psychology, behavior, and things like that, then YES, I would absolutely recommend it. Also, if you’re a parent, or you run an organization like a business or church, you and your family/organization could gain a lot from you reading this book.

tl;dr

The Power of Habit explores how habits work, how we can change them, and how we can use them to our advantage. If you want to change something about any aspect of your life, you should read it.

Once upon a time

We went to the store this evening, yet again.  They did not have what we were looking for, yet again.  So we will have to order it off the internet, yet again.

Anydangways, on our way home there were some spots of cool fog.  And that got mee to thinking about how we often refer to “dense fog.”  That got mee to thinking about the word “dense.”  When I was younger I used to think it meant “light,” “airy,” or “fluffy.”  So then when someone would give mee bread or cake to try and call it “dense” I assumed it would have the consistency of angel-food cake.  I was confused by it being more like pound cake instead.  I do not remember when I finally understood, probably a science class when talking about mass, or maybe a social studies class when talking about population.  In any case I figured it out.  Some people may wonder why I misunderstood the word in the first place.  This is why.  I often heard some individuals called “dense.”  These are the same people I heard called “air-heads.”  So in my young-brain-logic, dense=full of air.  That’s my story and I’m sticking to it.

*Okay, so “often” could have been only once or twice for all we know, then again it could have been everyday.  (Un)fortunately, I do not remember who was called this or by whom, I just remember hearing it.

 

And just for fun, here is a picture, or two, of an amazing little girl typing the text after the picture.

 

YHGJGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG6

TTJHY555sgsssssssssssssssssssssssccdwdqsss7444nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnjghbbbbbbbbbbbbbbbb+

633.

3…

020789.89+.66

3

 

nj

k,o,o,o,o,o,o,o,o,o

 

+++52525252521*99*9*2jhihhhhhhhhhh  hhhhhnnn77777,,,,,jkukun jnjjjjo6yygjujynfg0 .236663666666666 vc’ c[vbccv999999999999999999999999999ui

96.

2.

The Great Tree Massacre of 2008

Yes this quiz is from a pictures taken over a  year ago.

answer83

On December 19th, 2008 at almost two in the morning we heard a noise.  It sounded like something had fallen on the house.  We put our coats on, and went outside to see the above.

We were worried that the branch may have been too heavy to leave hanging on the cable that feeds us our internet.  We also did not like the idea that it might fall on the car.

This branch was about the diameter of a healthy cantaloupe, and was very long.  Jacob went up to it to see if he could just push it off to get it away from the wire.

2008 12 19 (1) blog

Upon closer inspection, it was really really big.  He gave a few heaves, and decided it would be best to move the car out of the way so as to not allow the chance of the branch falling on the car.  So, he ice-picked his way into the car, kept the door open to see and backed the car up a ways.  He went back to the branch and gave it some good pushes.

2008 12 19 (5) blog

Down it came.  You can see where the car had been.  The sound from the branch hitting the ground was loud, and the vibrations from it hit other places where ice had formed, and we heard lots of cracking and popping around us.  The best we can describe it is to say that it sounded like a battle field.  The apartments across the street had lots of ice on the roof, that (we believe) in response to the branch noise, cracked and slid off the roof into the parking lot.  We hope all the cars were ok after that.

2008 12 19 (3) blog

The ice storm really was pretty to look at even though it really was not good for the trees (or likely the animal life either).  This is one of the electric lines next to our house that we saw at that time.

2008 12 19 (9) blog

This is a picture taken after getting up for the day.

I hate that it is pretty

Snow.  It is cold and nasty.  It is so pretty.  In fact I think I really like to see it drifting across the road in the swirls of wind.  If only it were not so stinking cold!

Tonight as we were driving, I was reminded of a song in Beauty and the Beast.  “Through the mist, through the woods, through the darkness and the shadows, it’s a nightmare, but it’s one exciting ride.”  And that describes the mid-west to mee tonight.

Only problem now is, we don’t own that movie.  And until I can watch it, that song will be stuck in my head.

This is not fair

So last spring/summer we had the back door open for fresh air, a lot.  A mouse came in, so we got traps and caught it in just a couple days.

This fall another mouse dared to enter the house.  We set the traps again, and it was caught with-in the hour of setting.

We had one still set along the wall, just waiting in hopes that we would not catch another.

We went out of town for a week, and the trap was empty.

The temperatures dropped, a mouse came in for a snack.  It died.

We went to pick up more traps (because even though it says reusable, let’s be honest here, I am not un-clipping the mouse and using that nasty thing again!) just in case we need them.  The temperature outside keeps dropping, and I don’t want to be outside!

The price of the traps this time was $6.88, I think-once I find the receipt I will know for sure.  This evening we were at the store getting other supplies in that area of the store, and passed the traps display, and this is what I saw:

IMG00315mouse traps

It is the original price again.  It makes me so stinking mad!!!!!

We figure that because the outside temperatures dropped, many people were having trouble with the mice coming in, and the store (or rather the people who run it) decided that they might as well make extra money off the people who already have enough problems in their lives.  And now that the traps are in less of a demand, the price has dropped back to the original rate.

Now, if I can just think of how to make this work to my advantage….  Any ideas?

Sandwich Cookie Showdown

scs jacob start scs mee up next

It’s well known among our readers that we are, in fact, a couple of nerds. Being nerds, we like to apply science wherever we can. Tonight, we used science to finally answer a question that has long plagued mankind: Are Oreo brand cookies really better than their store-brand equivalent?

scs the competetors
scs cookies3 scs cookies 2 scs cookies1

Here we present our methods and our findings for peer review.

Our experiment was conceived when Marcia (hereafter known as “Subject B”) acquired a package of Oreo cookies as “payment” for babysitting the daughter of some friends while they went roller skating. Since we usually purchase the store brand cookie from Wal-Mart (because it is less expensive), we began to wonder if there was really a significant difference between the two products. We devised an experiment where each of us would sample different cookies blindly, in a random order, and rank them on flavor.

The materials for our experiment were as follows:

  • Two Oreo brand sandwich cookies
  • Two Wal-Mart “Great Value” brand sandwich cookies
  • Two Hy-Vee “Dunkster” sandwich cookies
  • One black sleep mask
  • Water
  • Digital Camera
  • Paper plates

scs before start

Subject A (AKA Jacob) was the first to undergo the rigorous test. He put on the sleep mask and then took a small drink of water to clear his palette. One of each type of cookie was placed on a paper plate. When Subject A was ready, he was given the first cookie. After taking one bite of the cookie, he took another drink of water, and then repeated the process with each cookie, until he had sampled each one.

scs jacob eats

scs jacob tastes

scs jacob drinks

Subject A then wrote his results down and hid them, so that he would not influence any other subjects.

The experiment was then repeated with Subject B, who also wrote her results without influence from any other subjects.

scs mee tastes

scs mee chews

scs mee contemplates

scs mee drinks

The subjects sampled their cookies in the following order:

Subject A Subject B
1. Great Value Oreo
2. Dunkster Great Value
3. Oreo Dunkster

scs judgement time

When the subject’s results were compared, they ranked the cookies in the following order, from best to worst:

Subject A Subject B
1. Oreo Oreo
2. Great Value Great Value
3. Dunkster Dunkster

scs bitten samples

Each of the subjects independently ranked the cookies in the same order, with the Oreo cookie best, the Great Value cookie second, and the Dunkster cookie third. When the subjects’ notes were compared, each agreed that the Oreo was the best cookie, and the Great Value cookie was a very close second. The flavor of the Oreo and Great Value cookies was nearly identical, but the Oreo cookie prevailed in texture and “mouth feel.” The Great Value cookie was drier and harder than the Oreo. The Dunkster cookie’s flavor was less sweet, one subject described it as “more like baking chocolate.” The texture of the Dunkster cookie was described as “almost stale-like” and “waxy or greasy.”

The bottom line:

All subjects agreed that when a sandwich cookie craving needs filling, the Great Value cookie is an excellent choice for its relative price and flavor, but when the full sandwich cookie experience is of the utmost importance, the Oreo brand cookie is an absolute necessity.