Post-surgical deaths in Scotland drop by a third, attributed to a checklist | Hacker News Reader

Post-surgical deaths in Scotland drop by a third, attributed to a checklist

bbc.co.uk

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My former roommate is a pilot. When I first met him, I noticed that he uses checklists for just about everything, even the most basic everyday tasks.

After some time, I decided to apply that same mentality to my own life. Both in private and work situations.

I get it now. Checklists reduce cognitive load tremendously well, even for basic tasks. As an example: I have a checklist for when I need to travel, it contains stuff like what to pack, asking someone to feed my cat, check windows are closed, dishwasher empty, heating turned down, etc. Before the checklist, I would always be worried I forgot something, now I can relax.

Also, checklists are a great way to improve processes. Basically a way to debug your life. For instance: I once forgot to empty the trash bin before a long trip, I added that to my checklist and haven't had a smelly surprise ever since ;)

Good checklist design is not trivial, however. I use checklists professionally, and the list rapidly accumulates cruft for problems that have been solved by design. E.g., suppose one time someone forgot to sign your software release. "Verify release has been signed" is added to the checklist. However a bright soul also integrates signing into the release build. Thus the problem is essentially solved once and for all, but the item will remain on the checklist in perpetuity, which adds overhead & decreases confidence in the checklist process.

I think they make sense for infrequently exercised routines of moderate complexity that are 100% execution. A complex but limited scope machine like a plane is really an ideal example. I guess preparing for a vacation could be another, although I get caught up because packing is totally different every time. I suppose I checklist myself when I rappel or go skiing ("Skins, skis, boots, ... working up the body")

> but the item will remain on the checklist in perpetuity,

Why do you say this?

Everytime you see a system flaw because of a missed step, you add to checklist. Everytime you have a process flaw because of a uselss step, you remove from the checklist. There's no problem here, checklist maintenance can be a step in the checklist.

> ("Skins, skis, boots, .

"Spectacles, testicles, wallet, and watch!"

A release checklist (for us) is inherently very risk-averse, as its raison d'être is to prevent a very expensive & dire catastrophe, and every item on the list is (metaphorically) "written in blood" [0]. As a result it's politically intractable to remove anything.

[0]: https://medium.com/war-is-boring/u-s-navy-supercarriers-domi...

Long time ago when I was living with my parents, our family checklist was "Gas, light, water, cellphone, cat".

Check that the gas stove is off (important). Lights off. No running water (after a few, um, incidents). You didn't leave your phone, did you, and make sure the cat didn't run out (he'd always try).

I always wondered why "lights" were on the list, since nobody gave a damn about electricity bills.

Guess for the same reason that "testicles" are in the parent comment's list :)

I think a more modern version of that last checklist would include keys and phone.

> I think they make sense for infrequently exercised routines of moderate complexity that are 100% execution

Yes. There have been several formal studies of this effect, e.g. [0]. Checklists offset skill fade, which is in effect the 'forgetting curve'. Some skills (the classic riding a bike) last for ages, others (a good example being field fault diagnosis) are lost very quickly even with good initial training.

Incidentally, I once made a good camping packing checklist by making an inventory of the contents of my car as I unpacked it at the end of a holiday and the things I'd forgotten were still fresh in my mind.

[0] https://www.gmc-uk.org/-/media/about/skills-fade-literature-...

Sounds like you need to add "Periodically review & maintain checklist" to your checklist.

And don't forget to make a Checklist review checklist so you don't mess up your checklist review.

> I suppose I checklist myself when I rappel or go skiing ("Skins, skis, boots, ... working up the body")

This is a perfect example. I have a snowboarding checklist and it's reduced the cognitive load of packing tremendously.

Things to do the night before, stuff to wear for the drive, stuff to pack, what to include if I'm expecting extra cold weather, and a final checklist for things to do in the morning (e.g. get lunch out of the fridge).

For travel I have a checklist of things that I always need to take (toiletries, spare phone battery, Nalgene, pajamas) and then the stuff that varies is all I have to think about. Almost every time I travel there's something on my list of "stuff that always gets packed" which I would have forgotten.

I even take it a step further and I have a dedicated storage bin for all of my ski gear. When I get home, I religiously wash everything, then put it all 100% back in the bin. Next time I go skiing, I just grab everything out of the bin. Rinse and repeat.

Hell, I do the same thing when traveling. I 'get dressed' in my head to check that I'm entirely clothed. If I weren't as good at visualizing things I'd probably just write it down.

I never forget socks but I've had to buy a few toothbrushes and deodorant...

Another situation in which it helps I think : cooking. At least for me a checklist (written or mental) helps keeping the kitchen clean a makes better meal. For a few years now I've started to plan my cooking like I plan more abstract algorithms.

Recipes are checklists too.

Also: Mise en place

I trust that someone in the near future will mess with the release build process and the signage will be dropped. Or there might be cases when the signature is suddenly invalid for reasons you cannot forsee yet. Keep the item on the list, especially if it checks the outcome of a longer process.

Maybe an item on the checklist to refactor the checklist (as needed)?

Or maybe a checklist for refactoring all the checklists?

/this could get out of hand...

You don't need that in the checklist. But what you do need is a periodic review of checklists and other procedure and process documents.

Suppose you have training material for new hires ("How we use git 101"). Do you hand them the same document from 10 years ago? Does it have accurate setup instructions (now you use Bitbucket and not Gitlab or vice versa, and it presents internally on a different domain).

All of these kinds of documents should be reviewed with some frequency (and ideally you should have a way to submit changes outside of the explicit review times, the explicit reviews are to catch things that weren't found earlier; wikis can help here). If you don't, then you do end up with the problem being discussed. You'll have a lot of checklists or procedures being done "because it says so" and not because they're needed.

I would argue that you want an automated check for "verify release has been signed" then if it fails you are alerted. This is better than manually checking it every time or assuming it will always be signed. A trust but verify approach. Then one day you may find that a trusted cert has expired and signing is broken or a key is not available b/c it got accidentally deleted etc... Lots of things can go and will go wrong.

I confess to not usually using a checklist when I travel because most times are a bit different. What I do though--I travel a lot--is I have a couple containers of "travel stuff" down in my kitchen including some pre-made kits that I just throw in my bag. I pick out what I need, add clothes as needed, and that works pretty well.

> I confess to not usually using a checklist when I travel because most times are a bit different.

Don't you find that most trips have a ton of stuff in common though? Pajamas, contact case/solution, loofah, spare phone battery, ear plugs, phone charger & battery charger, reusable water bottle, etc. always go with me on every trip.

IMO the stuff that always goes is the stuff that I tend to forget, exactly because there's nothing unique about this trip that would make me remember it. If I'm going to the beach I know I need my swimsuit and beach shirts because I can walk through my activities and think about what I need for each one. But I'm likely to forget pajamas because I'm not thinking about "go to bed every night" as an activity to plan for.

This is why I use OmniFocus for my travel checklist: nested lists. If I’m not going on a ‘work trip’ I can just tick that whole sub-list off with one tap.

Checklists FTW. Nobody above me has mentioned Atul Gawande’s book ‘The Checklist Manifesto’ so, just on the off-chance you’re not aware of it, there you go. I loved it. (Gawande is the doctor who implemented the checklist in this article.)

I've been using packing crates, which helps.

I have a packing crate for socks, one for underwear, one for causalwear and pants.

Then I just need to think how many nights I'll be gone to pick how much goes into each.

(Also reduces space in my carry on so I have room for conference schwag on the return leg)

A good reusable checklist system can help with this. I've been using an app called SplashShopper since the Palm Pilot days that lets me choose what I need for any particular trip from a list of common items. This lets the list adapt to the particular needs of each trip. It's the only app I've ever found that hits this sweet spot of reusability. Unfortunately the company that makes it does a poor job of updating it for iOS, so I keep an ancient iPad around just so I can keep using it.

> Good checklist design is not trivial, however.

I understand you're saying, but this statement exemplifies so well something I think I have gotten worse at since becoming a software engineer.

In my previous life, if I tried to apply checklists to my life, I would have taken a naive approach, applied my best effort, and that would be the end of it.

Now I would be much more likely to consider edge cases and counter-examples, compare my checklists to the "optimal checklist", and as a result I might fall into a checklist-design rabbit hole, or else constantly question the efficacy of my checklists in knowledge of the true complexity of the problem.

I don't think it's always beneficial to think in those terms.

I feel like some people have vastly different sensitivities to doing pointless things. There are some people who would see items like that on the checklist, and go, okay, it's a minute to check that, no big deal, I'll do it and get on with my life. There are people who look at it and are almost offended that their time is being wasted by process. I don't really know what to DO about this, but I do find it's one thing that makes collaborating difficult when a group has members with vastly different tendencies in this regard.

>"Verify release has been signed" is added to the checklist. However a bright soul also integrates signing into the release build.

If that bright soul also added a 'verify the signature' step to the build process, and the ability for the build system to know that signing failed, you've automated the entire thing and now your checklist is documentation for the build process.

Curating a list isn't about building it as much as it is about maintaining it.

Then remove it from the check list? They're not immutable.

Create a checklist to review your other checklists on a schedule?

This is described in the book called "the checklist manifesto". Very good book by the way.

https://www.amazon.com/Checklist-Manifesto-How-Things-Right/...

Agreed, the book was very well written and the audiobook had a great narrator.

Because of that book, I'm not surprised that the checklist reduced deaths, but its a bit shocking that its by a third. Then again, the base rate was very low to begin with, showing that surgery teams were already doing a seemingly good job:

"The death rate fell to 0.46 per 100 procedures between 2000 and 2014, analysis of 6.8m operations showed."

Still, over 6.8 million operations, is that 15,000 survivals? Wow.

One big difference, I've always suspected, is that a plane crash is very visible and affects hundreds of people at once.

Somebody sick dying in hospital, on the other hand, is just something that happens, and draws very little attention - even though way more people are affected than in plane crashes.

So, the clustering and visibility of plane crashes leads to excellent check list discipline and other best practices in aviation, by and large (CRM, Crew Resource Management, is another thing Atul Gawande brings up in The Checklist Manifesto, and also eminently transferable to surgery), while I suspect that in surgery it is easier to drift away from best practices again without anyone noticing.

That's why these large studies and the educational efforts of Dr Gawande and others are so important.

edit: typo

Yes, that’s probably the reason because mistakes in health care is an absolutely massive killer. In the US alone it’s responsible for about as many deaths as if two jumbo jets collidee with each other every day. The number of people dying from the simple fact that health care practitioners are humans and humans get tired, drunk, angry, careless or just plain stupid for random reasons is mind boggling.

If we saw a midair collision of jumbo jets every day however the public would never accept it.

https://catalyst.nejm.org/medical-errors-preventable-deaths/

Read this: https://www.newyorker.com/magazine/2007/12/10/the-checklist

Same author as the book, but earlier. Contains all the meat, but none of the repetitions and the tenuous analogies.

Gawande had enough for a long-form article, but not for a book, and IMO it shows.

The book isn't bad. It's just that the essay is better.

There seems to be minimum book size that forces inflation in a whole genre of self-help books that genuinely have good advice. I've read books where all of the advice I need is in the end-of-chapter checklists.

On one hand, it's good to err on the side of too-long a book, as it's easier to skip fluff than to seek out more details, illustrations, and alternative phrasings that aren't in the book. On the other hand, it's annoying to have the extra weight in volume in one's book collection.

I was lamenting this exact thing to a friend the other day. Books are just too long for most self-help advice and it ends up being 80% filler.

The worst is when the first three chapters are about how rich/smart/successful you'll become by reading this book! (Except for the first three chapters, of course, because those are just advertisements for the book you already acquired.)

To solve this I subscribe to blinkist where they have summarized every self help book into a 15 minute read. It costs money but the summarization of content is worth it. I've read hundreds of self help essays (books) with blinkist.

Does not the book also give more insight about how applying the principles to someone everyday life ?

I also didn't think this. I've read the book but not the article, and while the conclusion seems fine, a lot of the material in the book is stretched.

The one that bothered me the most was the inclusion of the India soap program as support for checklists -- those are entirely different models.

The soap model involved researchers handing out free soap, and teaching people that they should wash with the soap in any of a set of specific circumstances:

    - once a day (full body)
    - before preparing food (hands)
    - before eating (hands)
    - before distributing food to anyone (hands)
    - after defecating (hands)
    - after wiping an infant (hands)

This made a big dent in the prevalence of disease in experimental neighborhoods. Great! This was a good idea. But it's not an example of a checklist. The concept here is that, every time you do anything at all, you see whether it's one of those five hands-washing circumstances, and if it is, then you wash your hands. This is the opposite of a checklist, where you perform a series of verifications whenever you take a specific particular action, not whenever you take any action at all.

(Obviously, people can't handle the mental load of "before doing _anything_, check to see..." and instead would have added "wash your hands" to the appropriate five behavioral sequences. That reduces the mental load from (1) a constant mental drain on any activity of any kind to (2) learning five things. But if you make that switch, you stop having any relationship to the checklist concept at all.)

Why do you think so? I don't.

The article in The New Yorker is superb, you should really take a look. What could be missing there?

The medical community uses checklists. They've been using checklists for a while. A number of studies found that they only help for a few months, while they're new.

That said, "the medical community" is not a homogeneous monolith, and you can absolutely find regional variation in what checklists are used for, how detailed they are, how closely they're followed, how people are accountable for keeping to them, etc.

"The Checklist Manifesto" chose to overlook the studies about how transient the benefit of checklists is.

> A number of studies found that they only help for a few months, while they're new.

This 2014 review looked at 34 studies that looked at the effectiveness of safety checklists:

> The main findings were improved communication, reduced adverse events, better adherence to standard operating procedures, and reduced morbidity and mortality. None of the included studies reported decreased patient safety or quality after introducing safety checklists.

> Safety checklists appear to be effective tools for improving patient safety in various clinical settings by strengthening compliance with guidelines, improving human factors, reducing the incidence of adverse events, and decreasing mortality and morbidity. None of the included studies reported negative effects on safety.

So I'm going to ask for a citation on that claim.

https://www.ncbi.nlm.nih.gov/pubmed/24116973

Could like point out the studies you mentioned?

The studies concerning long-term impact of surgical checklists I found all claim an improvement.

> Sustained use of the checklist was observed with continued improvements in process measures and reductions in 30-day surgical complications almost 2 years after a structured implementation effort that demonstrated marked, short-term reductions in harm. The sustained effect occurred despite the absence of continued oversight by the research team, indicating the important role that local leadership and local champions play in the success of quality improvement initiatives, especially in resource-limited settings.

https://www.ncbi.nlm.nih.gov/pubmed/25806951

The way they run these studies is crazy to me:

>Only 3 of 22 operating stations (13.6%) had a functioning pulse oximeter prior to the intervention; accordingly, a pulse oximeter (model 7500; Nonin Medical Inc) was installed at each operating station as part of the implementation effort

The addition of essential medical equipment surely won't bias our results!

> A number of studies found that they only help for a few months, while they're new.

Interesting, that kind of surprises me. Without going to research it right now, I wonder how/if the efficacy is affected by things like going through them in tandem with a partner, or doing them out loud or with exaggerated physical acknowledgements (like the Japanese train drivers who point out signs/notices along their route as a way to maintain focus on those notices).

A speculative hypothesis related to this (based on my own experience as someone who has read the Checklist Manifesto and is a big advocate for checklists):

Over time people internalize the checklists because they unwittingly conclude the reason for the checklist is to learn a new procedure rather than foolproof their procedures and avoid errors. As a result, they start to skip the checklist or get sloppy with it.

There are a couple other points related to this that I believe Gawande does address in his book:

1. Doctors (more generally experts or egoists) will be resistant to checklists because they find them unnecessary (given their experience or expertise).

2. Checklists need to managed with regular review and updates.

You can boil Gawande's book down to: "Start using checklists because they're really effective." But his book goes deeper than that and addresses some of the underlying human factors involved in getting an organization to use checklists effectively.

While we're guessing, I would figure it just becomes drilled into people as automatic & a given, the same way you buckle your seatbelt without thinking about it.

> "The Checklist Manifesto" chose to overlook the studies about how transient the benefit of checklists is.

It's been almost a year now since I read this but I'm fairly certain Atul touched on this, either in this book or in his book "Better", that after those implementing the changes left, the departments often fell back into old habits.

Could this be the case?

This isn't just with checklists, but a typical behavior of organizations (at any scale). Organizations are systems, systems tend to fall into a steady state of performance, quality, etc. after some period of time. If you draw the people's attention to something (checklists, quotas, threats, praise, etc.) you can see a temporary boost in performance, but unless the culture changes the performance tends to return to that same steady state (maybe slightly enhanced or worse).

In order for the benefit to stick, you need to actually change the system. Otherwise, complacency or other things will return when the pressure and other early benefits wear off.

That's an interesting point, can you provide a link to those studies ?

Are these paper based? Any checklist apps out there for our daily use?

GitHub and GitLab support task checklists in Markdown and also project boards which add and remove labels like 'ready' and 'in progress' when cards are moved between board columns; like kanban:

- [ ] not complete

- [x] completed

Other tools support additional per-task workflow states:

- [o] open

- [x (2019-04-17)] completed on date

I worked on a large hospital internal software project where the task was to build a system for reusable checklists editable through the web that prints them out in duplicate or triplicate at nearby printers. People really liked having the tangible paper copy.

"The Checklist Manifesto" by Atul Gawande was published while I worked there. TIL pilots have been using checklists for process control in order to reduce error for many years.

Evernote, RememberTheMilk, Google Tasks, and Google Keep all support checklists. Asana and Gitea and TaskWarrior support task dependencies.

A person could carry around a Hipster PDA with Bullet Journal style tasks lists with checkboxes; printed from a GTD service with an API and a @media print CSS stylesheet: https://en.wikipedia.org/wiki/Hipster_PDA

I'm not aware of very many tools that support authoring reusable checklists with structured data elements and data validation.

...

There are a number of configuration management systems like Puppet, Chef, Salt, and Ansible that build a graph of completable and verifiable tasks and then depth-first traverse said graph (either with hash randomization resulting in sometimes different traversals or with source order as an implicit ordering)

Resource scheduling systems like operating systems and conference room schedulers can take ~task priority into account when optimally ordering tasks given available resources; like triage.

Scheduling algorithms: https://news.ycombinator.com/item?id=15267146

TodoMVC catalogs Todo list implementations with very many MV* JS Frameworks: http://todomvc.com

Reusable Checklists could be done with a simple text document that you duplicate every time you need it no ?

For sure. Though many tools don't read .txt (or .md/.markdown) files.

GitHub and GitLab support (multiple) Issue and Pull Request templates:

Default: /.github/ISSUE_TEMPLATE.md || Configure in web interface

/.github/ISSUE_TEMPLATE/Name.md || /.gitlab/issue_templates/Name.md

Default: /.github/PULL_REQUEST_TEMPLATE.md || Configure in web interface

/.github/PULL_REQUEST_TEMPLATE/Name.md || /.gitlab/merge_request_templates/Name.md

There are template templates in awesome-github-templates [1] and checklist template templates in github-issue-templates [2].

[1] https://github.com/devspace/awesome-github-templates

[2] https://github.com/stevemao/github-issue-templates

I really want slack to adopt these as well...

I'll often be on call with customer and create a checklist on MacOS Notes on the fly. Then will copy paste that in slack or github for simple tracking.

Mattermost supports threaded replies and Markdown with checklist checkboxes

You can post GitHub/GitLab project updates to a Slack/Mattermost channel with webhooks (and search for and display GH/GL issues with /slash commands); though issue edits and checkbox state changes aren't (yet?) included in the events that channels receive.

Kanban boards e.g. Trello, Kanbanflow, Microsoft Planner, and others. They all support checklists, and you can categorize/organize as you need.

“A simple, free and powerful way to manage your team's recurring checklists and procedures“ https://www.process.st/ Paid features include 3rd party integrations. (Disclaimer: neither a customer nor employee of the company.)

Do any of these let you re-use your checklists, though? Planner at least is pretty useless for this, as I don't think there is a 'reset all items to un-checked' feature, or even basic stuff like re-arranging your list.

Click the "..." and Copy Task. It will generate the checklist again without anything checked, then just mark the old as complete.

You'd need some system to mark when one list ends and the next begins, KanBan just treats them as individual tasks.

> even basic stuff like re-arranging your list.

All of them let you re-arrange your list. Is this a mobile specific issue?

> This is described in the book called "the checklist manifesto".

You might notice that the book was written by Dr. Gawande, who implemented the checklist in the fine article!

I second that, excellent book.

I've also read it, for anyone thinking about buying it, i think it can be completely summarised by:

'checklists are very very good. You should really use checklists'

Now if you require further info on why they are good, by all means read the book, i just found it was a blog-post, if not a tweet, expanded to a book, YMMV.

That's exactly what it was. Atul Gawande wrote a column in the New Yorker [0] and was presumably offered a deal to expand it into a book.

[0] https://www.newyorker.com/magazine/2007/12/10/the-checklist

> 'checklists are very very good. You should really use checklists'

If you stop at that you miss a big part of the book where he describes that not all checklists are equal, what makes checklists useful (i.e. you should not state the obvious in a checklist and he goes at length to explain why), and how you spread the usage of checklists in an organization. That's a lot more important than "checklists are very very good".

That's the basic gist of all productivity and business how to/advice books. They're all a fairly simple set of ideas with 100 examples and testimonial style stories about just how revolutionary it is or how much it changed executive XYZ's life.

> I've also read it, for anyone thinking about buying it,

Or perhaps see if your local library has it.

I've reduced my book purchases, and generally only consider buying something nowadays if I still enjoy it after the second/third reading (from the library).

One additional thing I got out of it that wasn't totally obvious to me beforehand about checklists is that they work better if they don't attempt to be exhaustive. Focus on the major items that should be "checked".

I kindof agree, but he also had other interesting nuggets such as having all the medical staff introduce themselves and why they are there in the surgery room before any cutting begins.

It's interesting to think how often dumb errors can be caught just by making sure everyone in the room is there for the same surgery (i.e., repairing a joint, not cutting off a limb). Correcting that confusion before cutting makes me feel better.

The only addition I would have to that summary is:

"And yet, most people think checklists are beneath them. They are insulted that someone with as much experience as they currently have would require a checklist."

Here is a Hidden Brain episode on it: https://www.npr.org/2017/10/30/559996276/the-trick-to-surviv...

Can't tell you how happy it makes me to discover I'm not the only one who does this. My wife says it drives her nuts but I'm pretty certain she's also delighted by how we never forget anything before or during a trip.

We did something similar for example: left a tray of leftover food in the oven (turned off) just before a trip and came back to a pulsating surprise. I added "Check the oven is off and empty" to the list of things to do "Just before we leave" and it's never happened since.

That said, there are several hundred things on my generic version and it sometimes feels a bit daunting having to start afresh each time we travel but I think so far, it's been worth it.

I keep threatening to do a trip without it and see just how many things we forget, don't do and screw up. MAybe one day... :)

A 100 item checklist?

I just throw some stuff in a bag and worry less. Never fails. If I forget something it probably was not that important and I can just buy it at the airport / when I land.

Does your local airport sell passports and prescription medication?

I just fundamentally don't understand the statement, "If I forget something it probably was not that important". How does one follow from the other?

Having 100 items on the checklist doesn't mean you need to act on all of them. You can go through your normal packing, then take a few minutes to scan through the checklist for anything you may have forgotten. Most items may be irrelevant to that trip. Just skip them.

This is my approach too. My time in the military got me into the habit of checklists for everything and I carried it over into my personal life for many years after I got out. I never forgot anything, but I was perpetually lugging around a ton of stuff the I never used.

It's been many years since I stopped worrying about it, and I've yet to have even a single instance come up where I forgot something important enough to be a real hassle.

Checklists are great for surgeons and pilots. The cost of missing something in those professions can literally be life or death. If I forget to pack something when I go on vacation, the most it could possibly cost me is money.

I perhaps should have elaborated a bit about the number of items. It is broken up into sections like: * Do well before we leave: e.g. arrange insurance, book seats on flights. * Do just before we leave: e.g. engage window locks, turn off heating, empty dishwasher

Then sections for hand carry, electronics bag, wash bag, suitcase and various subdivisions within each.

I found the best way to manage it is to make one giant list so it might have a kite and a bucket and spade in the "misc items" for example. When we're planning a trip, I copy that list to a new place, edit the title accordingly and remove all the items I'm sure we won't need. Like the aforementioned kite and bucket if it's not a beach trip. Or the car pack with chargers, suction cup for phone navigation etc. if we're not renting a car.

I agree that it'd probably be mostly okay if I went rogue and I can always buy stuff in the airport or at our destination. Notable exceptions being medications, passports, credit cards. I still garner some measure of comfort from knowing we have everything even if getting there can be a little stressful.

> I keep threatening to do a trip without it and see just how many things we forget, don't do and screw up. MAybe one day... :)

I don't have a checklist, and usually I'm fine. So, it's certainly possible :)

Also, I think if you have a list of over 100 items, maybe it's time to simplify it or break it up into sublists. That length itself probably produces more anxiety than saved by the list. It sounds like an over optimization

For background, I create todolists and checklists all the time in my life. Just so far, I haven't felt the need to make one for taking vacations.

I don't know how I'd live without checklists and Trello boards. Just running a family with a couple of kids, I don't get how people used to do this.

Each kid has their own schedule, their own list of items they need that day, their own homework.

When you shop, you need to know what to get for everyone.

And there's the paperwork, you have to decide what to buy for major purchases and pay for them all, and you have to sign up to various things like voting registries and local tax.

Add to that your work, where you have a bunch of tasks to do as well, various projects, bugs, meetings, and so on.

I lived through the pre-mobile, pre-everyone-had-a-computer era, and I don't get how people did anything. Paper diaries? Rolodexes?

The best way to organize things is to not have so many things to organize.

People certainly are busier now, but they seem to be a lot less focused on important things.

Kids playing used to be spontaneously organized by the kids, or even organized in advance by the kids. The amount of available greenspace in a neighborhood seems to be a lot less now, and play appears to be monetized and organized by adults and organizations.

"The more you know, the less you need."—Aboriginal proverb

Read Samuel Pepys diaries from the 17th century. They're available online in various forms. It's fascinating both what has changed and what hasn't changed at all. Pepys wrote these diaries primarily for his own use and so he sends to be largely honest (at least as much as we are honest with ourselves). He describes cheating on his wife, lying to people and so on.

Anyway, Pepys complains frequently that his day's work was lost because he was not able to meet with someone in the expected place at the anticipated time. That's just how things were then, you could neither phone to ask "where are you?" nor to say "change of plan I will now be at the old bridge until 4pm".

Simpler life. Less productive.

Perhaps more time to wonder, explore, and waste.

Perhaps less fulfilling and more difficult to achieve goals.

paper calendars on the fridge was a big part of our home organization pre-computers. :)

People simply did less

>Paper diaries? Rolodexes?

Carbon based one, ie brain.

My own anti-anxiety strategy for thinking like making sure the cooker is off, windows are closed etc. is to take pictures with my phone of everything (of course I never look at the pics).

I suspect there might be an opportunity for a "visual checklist" app that prompts you to take pictures of stuff....

NB I do use a paper checklist for remembering to take stuff when I go up mountains at the weekend - forgetting gloves when it is snowing is never a good idea.....

Adding a physical act (in your case taking a picture) has been shown to DRASTICALLY increase the rates at which items are completed.

The classic example of this are train drivers: https://www.atlasobscura.com/articles/pointing-and-calling-j...

Quote from the article:

"Originally developed by the now-defunct Kobe Railroad Administration Bureau in the late Meiji Period (the early 20th century), pointing-and-calling is known to reduce workplace errors by up to 85 percent, according to one 1996 study."

One thing I do as a pilot, btw, is that for each item on the checklist I touch the actual control (and sometimes even activate on and off again, for example the alternate static air intake).

It serves several purposes:

* it ensures that you actually look and check, not just say the magic incantation ("fuel selector valve: BOTH") out of habit, and

* for rarely used controls (such as the alternate static air source), it familiarises you with it once per flight, so you don't fumble around in case you need it.

Not all pilots do that. I wonder whether there are studies on whether this helps. Certainly, there are many cases of planes crashing because pilots forgot to do certain items, even though they were on the checklist and the pilots have gone through the checklist.

https://en.wikipedia.org/wiki/Lufthansa_Flight_540 ("The flight engineer was found to have failed to open the slat system bleed air valves as required on the pre-flight checklist.")

https://en.wikipedia.org/wiki/Helios_Airways_Flight_522 ("the flight crew overlooked the pressurisation system state on three separate occasions: during the pre-flight procedure, the after-start check, and the after take-off check. During these checks, no one in the flight crew noticed the incorrect setting."

> it ensures that you actually look and check, not just say the magic incantation

This reminds me of https://en.wikipedia.org/wiki/Spanair_Flight_5022#Flaps_and_... ("In the Takeoff Imminent verification checklist the copilot had simply repeated the correct flap and slat position values without actually checking them")

I wonder whether there are studies on whether this helps.

There are for trains. Presumably, it generalizes for human behavior, even if it's a plane, not a train.

https://www.atlasobscura.com/articles/pointing-and-calling-j...

NYC Train conductors now do this, pointing to the video display overhead the center of the station when they open the window.

Here's a video of people having a bit of fun with it.

https://youtu.be/i9jIsxQNz0M

(New York City imported the practice from Japan)

I've used a packing list for travel for a while now. My current method is to set everything up with checkboxes, uncheck them all beforehand and then recheck them as I pack or as I decide I don't need them for this trip.

I used to just group items by category (outerwear, electronics, etc), but now I've found it better to group items by where they're going to be packed (pockets, under-seat backpack vs carryon / checked bag).

Below that, I have short supplemental lists for things like camping, international, trips with swimming/beach, formal (wedding, etc), or trips longer than a week.

Also, a "Before You Go" list that's stuff to remember when literally walking out the door (take out the trash, shut down home theater computer, etc) that isn't realistic to pack or do in advance. Still a work in progress, but it really helps free up mental energy.

I do almost the same, but the “Before You Go” list is a great addition. I’ve got a couple of different checklists in Trello for different kind of trips: week of snowboarding, long weekend with my wife, business trip to conference, camping with family.

Gosh - that is freakily like my approach on all counts. Are you sure you're not me :)

I am struggling with how to best organize the items within a section. You have given me some ideas. Thank you.

As a pilot, we use checklists in a solo flight differently than in a crew flight. I fly solo flights by “flows,” and then use/review the checklist at the completion of a flow to confirm I did not miss any step. In general the flows are a right-to-left arrangement of things you do in a certain phase of flight. That way you scan over the things in order and do/verify everything in a single “flowing” motion.

I have checklists for almost everything. Recently I’ve started worrying that I’m depending too much on them because I should be able to think up things I need to do without these checklists. As in I’m not engaging my brain as much. But your comment just made me realize that now I have the cognitive load to do things other than remembering tasks. I recently passed two licensing exams without being stressed out that a lot of my friends failed. And I think I may attribute my checklists habit to that.

(Shameless plug from a happy user: I rely heavily on the Things app for Mac and iOS)

I credit checklists for being much more creative in my work and personal life. An in-memory checklist is a huge distraction. Once you flush it to offline storage, you have more memory for other things, like thinking about how to solve the harder problems in life.

I wish I knew this when I was 30.

I spend a lot of time getting checklists together at work, mostly for other people, and then ruthlessly removing extraneous items from the list (usually by fixing unreliable things that are of the sort: step 5: Do X. step 6: double check that step 5 actually happened)

I get lots of credit for the former, but maybe one in five people see the latter as the bigger contribution.

We end up having to deal with things when we are tired. You have to make them so an idiot can do them, because some day you will be that idiot. All day exhausting meeting followed by a major emergency. Kid up half the night with a fever. New video game just came out. Bad dreams, whatever.

With regard to the difference between pilots and surgeons in this matter, it has been noted that the latter are not personally at risk from not using checklists. I am not suggesting that surgeons deliberately or cavalierly put patients at risk, but risk to oneself has a way of concentrating the mind.

There's an anecdote in The Checklist Manifesto which backs this up. I'm recalling from memory, so the details may be off, but when they tried to roll out a checklist program into a hospital, many of the surgeons resisted, feeling that it was insulting. After having used the checklist process for a while, this sentiment remained, but when surveyed "If you were going under the knife, would you want a surgeon who uses the checklist process", nearly all of the surgeons answered "yes". (when their own life is on the line, suddenly a checklist doesn't seem to repugnant)

Back in the 19th century, when Ignaz Semmelweis suggested that washing hands was a good idea, he met a lot of resistance. From wikiepedia, "Some doctors, for instance, were offended at the suggestion that they should wash their hands, feeling that their social status as gentlemen was inconsistent with the idea that their hands could be unclean".

https://en.wikipedia.org/wiki/Ignaz_Semmelweis

Yep. What surprised me: certain things end up with surprisingly long checklists. My "monthly" checklist at home has 30+ items on it, and it's not padded.

When I hit 50 I started making lists like a mofo, because I realized it would relieve my cognitive load. And it did, big time.

I do this. Everyone seems to think I'm insane however. This is the same people who's lives regularly descend into chaos doing the same stupid things over and over again.

It reminds me on my Mom. Whenever we were traveling, she wrote a checklist. Very organized. I do it now too, helps me to offload.

I would likely forget something if I didn't have a travel checklist. Something I keep in my Evernote notebook called, wait for it, checklists :-)

They are especially handy when on multi-stop travel where I'm spending all my time worrying about the logistics of the travel and meetings. It has definitely saved me from losing a number of phone chargers and razors over the years.

I see the appeal and do it to some extent. However I haven't finalized on a system for it.

I've realized that there is quite a bit of overlap between some of my lists and have been thinking that I'd like it to be a modular system. A checklist consists of a any number of items and sublists so that one can quickly combine them.

For instance, travel might optionally include the sublist abroad and/or skiing or summer. A work-related trip might add another set of items etc.

I bet there are apps for this and I think I found a few when looking, but I'm afraid of the managing overhead and would like access to it on my phone and computers without cloud bloat. Maybe git + vim-wiki or something is good enough (would also work well enough on an android phone with termux).

Modularity; Software Engineering problems :)

In human computer interaction they often talk about the "gulf of execution" - when the desired end state is known but it's unclear how to get there.

https://en.wikipedia.org/wiki/Gulf_of_execution

I've found that using checklists helps tremendously when working on medium to large projects (things that take more than a weekend to complete).

For example, if I want to learn a new technology, maybe I'll get a book on python, add the list of chapters in my projects tracking document, and strike them off one by one.

That sense of steady progress helps tremendously.

Checkslists force me to really have some kind of plan for achieving a certain goal - how I want to achieve something. Because I have to be able to write down the single steps.

Also checklists make it very easy to just get started.. just begin with the first task

And last but not least - I use checklists especially for things that I do NOT want to do at all (but I will have to do anyway). I am already annoyed (for whatever reason) by that task - so I want to minimize the amount of time I have to spend dealing with it. Therefore I use a checklist with the minimal amount of necessary steps to solve that problem or task, so I can get rid of it as fast as possible.

Maintaining checklists in documentation for software design reduces mistakes dramatically. Writing step-by-step exacting build instructions for one of our core products reduced the annoying requests for help I got dramatically.

I also have a checklist for trips. But I haven't been able to come up with other use-cases in everyday life so far.

In my twenties, I kept medical appointments in my head for me and both kids a year out. I never saw any point in jumping through hoops to put it in a calendar. It struck me as a pointless time waster to write things down that I was going to remember without writing it down -- and then have to also keep track of the calendar, check the calendar regularly, etc.

My messy stacks of papers made me look disorganized, but I could find anything important within ten minutes. In contrast, we routinely tore the house apart for an hour looking for something of my husband's.

He liked to organize and file and alphabetize. But the things he failed to organize often ended up in a heap on the floor. He did all that because he couldn't keep track of it mentally.

If your life works without checklists, don't worry about it. But if you find you start overlooking important details as you get older/busier/in a new and unfamiliar situation, you might revisit the idea.

Just don't rain on someone else's parade. Check lists work well for many situations and are especially valuable when lives are on the line for some reason (or similarly critical situations where mistakes often happen for various reasons).

Agreed, checklists can become a cargo cult. Also, checklists don't always need to be written down; just systematizing some mental checks can be helpful enough (e.g. "phone-keys-wallet").

I have an extensive checklist for trips. I’ve also got a daily one, which is partially for helping me get the day started off right by checking off a bunch of easy tasks, and partially just to make sure I don’t miss something critical. Ever forget about a meeting you needed to prepare for until you got the meeting reminder? I have a daily checklist item to give my calendar a quick glance to make sure there’s nothing I need to prepare for. It only catches something maybe a few times a year, but that’s worth it for the 10 seconds it takes me every day.

Pretty much anything I have to do more than once, that involves more than a few steps, I make a checklist for. I take pictures sometimes, semi-professionally. I have a checklist for what to do before I take pictures (pack the bag, charge the batteries, clear the memory cards), and after (brighten teeth in pictures, remove lint/spots from clothes, pick photos to put in my portfolio). At work I have checklists for design tasks, some of which are things to do, some of which are things to consider (does this need a review from security? does this need additional monitoring?).

There are people that can keep all this stuff in their head. I’m not one of them and I know it. Having checklists reduces my anxiety levels by an order of magnitude.

Personal:

  - Shopping lists
  - House errants (cleaning, maintenance)
  - Recurring payments (tax, power, water)
  - Car maintenance
  - Travel
  - Reading lists
  - Social (upcoming anniversaries, invitations, etc)

Work (I run a SaaS company):

  - Daily/weekly tasks
  - Tax filing
  - Deployments
  - Server health checks
  - Security checklists

edit: markup

Do you use any specialized software for that ?

Shopping lists are basically checklists.

In development, could be "pre-release/pre-push-to-production checks".

I've used them for video shoots too (e.g. pre-interview: "is camera charged? is extra battery on? are audio levels good? is frame ok? ND filter needed? took 10 second ambience audio sample? took b-roll?" etc.

We use checklists (to varying degrees of efficacy and adherence) at work. Obvious case: test procedures (for larger test cases and suites, not unit tests and automated tests). We also use them for things like peer reviews or releasing products to customers (to ensure we've asked the right questions, are releasing the correct product, have done all the things necessary to release the product, etc.).

Given that any routine could be made into a checklist, it seems likely that you have lots of everyday checklists that you do a good (or good enough?) job of keeping track of in your head.

Maybe for most things that you could use a checklist for, the effort just isn't worth it?

This is almost certainly the case. Consider the "simple" act of taking a shower and how internalized it is for most people.

If I remember anything from the "Getting Things Done" training is precisely this:

Writing down tasks saves you a lot of brain cycles and also removes worries, as otherwise you have to be constantly "refreshing cache" on pending tasks to not forget about them.

What do you have on the travel check list? Everytime I travel I say to myself that I should make a list but always forget or put it off.

Is there a good app for storing/sharing various checklists (travelling checklist, selling house checklist, etc.)?

I use the Things app. It allows you to have Projects Area with project inside (collapsible). The checklists inside can have sub-checklists. The sub-checklists can be marked “done” with a check mark or marked “not needed” with a cross. projects have headings so you can organize different tasks in that project.

Things only stores checklists. Doesn’t share them.

TickTick is my favorite.

Google Keep.

I recommend Dynalist or Workflowy

You don't know what you can't remember

Why care if dishwasher is empty?

I get the point of checklist for critical process. But I think it's counterproductive to drone your life away following task lists full of feature creep.

First with a little training you can put mental reminders in your mind, trusting yourself that they will show up when needed. It also helps with keeping your brain and memory in good working condition, and force you to stay in mental clarity and not being so overworked and tired that you have to rely on external list.

Second it's not robust to rely 100% on a task list being completed, sometimes forgetting something means that it's not that important. It's more important to rely on situational awareness to know what's need to be done and in what priority. The logic behind is pick something from the hot mess and make the whole better.

Third we can automate and delegate more easily now, quite often if you need to use a checklist, a script would be even better.

Think the "Checklist Manifesto" addresses your creep and clutter as basically a very bad design. In the book they went over several medical checklist iterations before they struck something sensible that improved conditions and saved lives. Most importantly, they changed culture in places to where a nurse was allowed to tell a doctor "no" without fear of reprisals, and re-framed checklist items to pay attention to a time window for administering antibiotics, not just whether a patient received them. The checklist that's helpful should fit on a laminated index card and it should list critical things. But, it's hard to distill the essence of something and most checklists end up as a loose thought vomit on pages.

I work on software related to medical drilling. Nurses run through simulations (mostly a situation where something has gone wrong) and get graded.

It baffled me to learn that this is NOT the norm at hospitals. Due to the stress of a situation-gone-awry and inexperience, some horrific things can happen.[0][1] In some situations you may only have a few minutes to enact corrective procedures. In any case without checklists (and without experience from running routine simulations) it's very easy to make mistakes or forget what to do.

I thought the checklists themselves were standard but it appears not...? The more I learn about hospitals' operating practice the more wary I become. I have no idea why hospitals aren't like the aviation industry and have checklists and expiring certifications. (Or maybe I heard wrong and I'm just completely wrong here.)

[0]: https://www.telegraph.co.uk/news/2018/05/10/premature-baby-d...

[1]: https://www.nbcbayarea.com/news/local/Dental-Anesthesia-Unde...

> Mead said the principal risk is a patient’s airway. He explained that a child’s breathing tube can collapse without warning under sedation.

> “It happens instantaneously,” he said. “You have maybe half a minute to make critical decisions about how you're going to manage that child's airway. You can't do that if you don't have somebody competent there helping you.”

I was part of a start-up developing checklist for high risk pregnancies. The checklists were developed by some of the best doctors in the country, who had already proved the worth of using checklists in their own practice. Even with all of that, we had unending push back from every single hospital we talked to. Eventually it killed the company because deals could not be closed. I still hear of hospitals saying they want checklists, and they keep saying that until they see one, and then they don't want it anymore.

Also, it wasn't a cost issue. The package was pretty cheap all told. The push back was in the "system getting in the way"...which was kind of the point unfortunately.

Atul Gawande talks about the importance of developing checklists collaboratively with the people who will use them as opposed to imposing them top down.

Many procedures in hospitals are checklist-driven. Peter Pronovost had an early, high-impact publication on the topic of bloodstream infection prevention with checklists: https://www.nejm.org/doi/full/10.1056/NEJMoa061115

I was surprised too, I worked on software for Surgery checklists a decade ago and thought it was standard practice and that only our digitization of it was new, the effects of a checklist have been known for quite a while now. The software I worked on would track every instrument and screw taken into a theatre (using hand scanners), the doctor would have his list of steps for the procedure and the equipment necessary, standard emergency packages were available for the exceptions, etc. It's not just for the direct patients either, some disease can survive instrument sterilization so knowing who else they've been used on can be important.

In the aviation industry pilots rarely get sued personally. IMO, the issue is more about legal system than it is about the medical one.

In the aviation industry, lawsuits aren't necessary. If a pilot makes a serious enough mistake, he dies. If we executed doctors when their patients died, lawsuits would be the least of their concerns.

If a pilot makes a mistake, he'll either die or lose his licence. Either way, his life is ruined.

> If a pilot makes a mistake, he'll either die or lose his licence.

I have a private pilot license. This is not true at our level, and is very often not the case at the big companies. Everyone makes mistakes; firing all the mistake-makers would not end well.

One of the reasons aviation is so safe (excluding corporate coverups like what happened a couple of times with Boeing) is that there is an emphasis on learning and making sure that mistakes never happen again - to you or to other pilots.

One of the exams for the Light Aircraft Pilot License for sailplanes in Europe has the multiple-choice question "Why is safety improved by submitting an official report of safety-related incidents?", where one option is "because then we can revoke the licenses of unsafe pilots", and another is "because then we can collectively learn from dangerous situations". Spoiler alert, the latter is the correct answer.

I can't speak for professional aviation, but I would be very surprised if the safety ethos isn't similar. Ruining a career after a mistake only leads to covering up mistakes. Why the hell is this a systemic problem at all? It's obvious it won't work.

No it's not. Career =/= life.

Because they're dead? Surgeons don't have that much of their own skin in the game...

If anything that sounds like a great reason for a doctor to use an industry standard checklist. "See exhibit A, documenting that my client followed the proper procedures". Not that that necessarily sounds great for patients with legitimate suits but for doctors it sounds useful.

Yep, so they'll fill the checklist beforehand just to make sure they're covered...

The solution may be found in the legal system and its corresponding arm, the malpractice insurers, if both were to mandate a minimal standard of care including the use of checklists.

I agree with the first part, but not with your conclusion.

There is way too much litigation. Hospitals and staff are using defensive legal strategies-- obscuring docs, discouraging internal (written) investigation, delaying urgent treatment with unneeded consultation (to get more signatures on a decision).

IMO, there should be legal protection against malpractice lawsuits. Increasing the attack surface will not help with the core problem:

Doctors are over-worked, they are human and they make mistakes. The solution is to either enforce work conditions for doctors (and people die) or accept those mistakes (and people don't get money when they are on the wrong side of statistics)

One of the issues I've seen in implementing checklists is actually the urge of people to put extreme detail into the checklist and people not putting items in a reasonable order. If you look at the referenced checklist (https://apps.who.int/iris/bitstream/handle/10665/44186/97892...) it is a very approachable list that acknowledges good skill in the people involved. Note that the "before patient leaves" checklist mentions the sponge count but the pre-incision checklist does not. That's because a sponge count is simply part of the job of an instrument nurse and something they always do when they open a pack of sponges.

It's also hard to insert checklists into established procedures. One thing you could do is attach them to important parts that are not allowed to be used until you read the checklist. For example, you could refuse to unwrap the main surgical pack until the pre-incision checklist is followed. Pharmacy could wrap the anesthetic induction drug in the first checklist. The surgeon could be responsible for signing the final checklist in order to get paid.

Keep checklists simple, use them every time. Put them in places where they have to be used.

Wise cautionary note. Use the right tool for the job.

Back when we used to burn "golden" CD-ROMs for releases: Our checklists were getting too unwieldy, we were still making mistakes.

So I started a Go/NoGo process, aka Roman Evaluation. Any one could stop the release for any reason. We'd fix the problem(s) identified, try again the next day.

(Of course, we fed each release's results back into process during the post mortems.)

Sounds more like TPS model.. "Build a culture of stopping to fix problems, to get quality right from the start. (Jidoka)" [https://en.wikipedia.org/wiki/Toyota_Production_System]

I haven't heard of the term "Roman Evaluation". Where does it come from?

Huh. Because we used thumbs up or down, we called it Roman Evaluation. But that's probably wrong. Releases required unanimous approval. aka blackballing https://en.wikipedia.org/wiki/Blackballing

And here is the checklist [1]

These seem like very common-sense things to check - Is this the right patient? Are the instruments sterile? Have we counted all the surgical equipment after the procedure?

[1] https://apps.who.int/iris/bitstream/handle/10665/44186/97892...

Maybe so. When was the last time you forgot to do something that was "common-sense"? Forgot to pick up your coat after work? Left your wallet on your desk? Now imagine each of those mistakes was fatal for a patient.

The issue is in the margins.

Maybe a shift-change caused the surgical team to be different from normal, so people aren't as comfortable with each other. There's social/professional pressure to fit within a hierarchy, especially with new people. Maybe a few people lower on the totem pole think something might be off, but don't want to say anything lest they risk appearing to undermine the surgeon.

So, at first it appears that a whole room of people would need to independently make the same mistake. But that's not so; only a few critical people need to make the mistake, and with enough ambiguity in the process (easily caused by anything happening 'out of the ordinary'), it won't be corrected some percentage of the time. Even seemingly trivial things.

The FAA found this occurring in the cockpit, especially from the '3rd seat'. A pilot and first officer may be 'in the weeds' dealing with the immediate threat of a situation, whereas others have the benefit of distance to reflect on a situation and observe more clearly. They don't get tunnel vision, and are in a better place to diagnose a tricky problem. However, they may not feel empowered to speak up, or feel they don't have the information the pilots do. Aviation has, broadly, sought to correct this and encourage anyone to speak up. Recently, this happened during the flight before the Indonesia 737 crash where similar AoA/MCAS issues occurred, but a 3rd pilot helped to address the situation.

It's always worth remembering that "after" can be after 10+ hours of continuous high-stress concentration, so remembering lots of little things can be very challenging.

Thanks, I can't believe this wasn't in article. The BBC might need a checklist of their own.

1. If the article is referencing a document, video, or picture, is it linked/embedded?

[ ] Yes [ ] Not available [ ] Not applicable

2. If the document refers to a third party report, is it linked?

[ ] Yes [ ] Not available online [ ] Not applicable

3. Are background sources linked to high-quality, external sources?

[ ] At least 3 links present [ ] We sat there for 1 minute and couldn't come up with anything that needs linking

4. Are needless generic internal links to category/tag pages etc. removed?

[ ] Yes

This is pretty interesting.

There seems to be a whole other list referenced: "Is the anaesthesia machine and medication check complete?"

Also the team are supposed to intro themselves along with their roles. I wonder if it often happens that someone is missing?

I'd bet more often it's two people who could each do the other's role and therefore wanting to be specific that one person is responsible for X and the other Y.

That's the sign of a good checklist. The idea is to free up mental processing to focus on harder issues. Let the doctor focus on the hard stuff and not spend excess time trying to remember the simple stuff.

As a life long patient, while I appreciate the checklists, I think some of the repeated rechecking is a bit much.

.... They haven't been using checklists? I've been getting so upset at the medical community recently. Pilots solved most of these problems decades ago. We've been trying to help them figure out these tools that we developed to save lives, but it seems like things are only changing one funeral at a time.

"500yr of progress being held back by 500yr of tradition" is highly applicable to the medical profession. There's a lot of arrogance floating around the medical profession as well that tends to put a damper on anything that might reduce human error.

Surgeons don't need checklists because they don't make mistakes, unlike those filthy three dimensional bus and truck drivers. /s

This explains why the American Medical Association is a top lobbyist.

Instead of adapting, they legislate.

And the fantasy that Physicians are unfailing experts leaves you after a you regularly interact with them.

I have had the same experience in other countries too, not just the U.S

Medical profession really comes across as arrogant and know-it-all, at least in my experience

> "500yr of progress being held back by 500yr of tradition" is highly applicable to the medical profession.

Is that true of most professions? The difference being we only really care when lives or large quantities of money are at stake. Probably more the later and less the former unfortunately.

Nobody cares what the skilled trades do. Tradition for the sake of tradition doesn't really get in the way of preventing human error in software, accounting or engineering.

Cops and doctors (in that order) seem to be the biggest offenders when it comes to rejecting process improvements to the detriment of society but there's definitely others. It's not a binary value.

>Pilots solved most of these problems decades ago.

In the safest planes (commercial airliners), pilots have systems recording their control inputs, and these can be used to directly attribute damage to/loss of the airframe to pilot malfeasance; the shame of a clear screwup will be clearly documented and in most cases, divulged to the public.

Medical professionals, on the other hand, seem to face a lower standard of accountability simply because it's truly far more difficult (if not impossible in some cases) to monitor all the variables associated with treating a patient compared to monitoring human-designed systems. I have to wonder if this epistemic quagmire where cause and effect are not necessarily tracked (and in some cases, not even truly understood) leads to a mindset that is more willing to write off negative outcomes as the result of external factors (comorbidity, patient age, patient adherence to physician instructions, even pure luck/probability) than tackle the tough problem of correlating personal behaviors and actions to distinct outcomes.

It's not hard to record all patient-doctor interactions. But it is almost certainly illegal in most jurisdictions, supposedly for patient privacy reasons.

That this also helps making doctor mistreatment claims hard to prove is hopefully an unintentional side effect. But you have to wonder...

Unfortunately, there's a lot of resistance to using checklists, from the nurses to doctors. I wish they'd just swallow their pride and worry more about how to improve than how it makes them look when their mistakes become visible and explicit to the people around them.

This is something of a case of "Physician - heal thyself".

I've advocated the use of checklists in software for decades. I wrote something 5 years ago and posted it here[0][1]. The discussion was enlightening. Read the discussions, keeping in mind the comments here about the resistance encountered by people in the field.

Many of the points in the discussions are useful and can be used to create and adapt checklists, but no, they are being used to dismiss them out of hand.

Checklists? We don't need to stinkin' checklists.

I've given up and just use them in my companies.

[0] https://news.ycombinator.com/item?id=7655018

[1] https://news.ycombinator.com/item?id=18522627

Reminds me of the old you are not done yet list. Couldn't track the one I'm thinking of down but found this: http://www.thebraidytester.com/downloads/YouAreNotDoneYet.pd...

I feel like I could use a checklist or two.

Only one company I worked with to date really used checklists and I firmly believe it was one of the reasons they were able to maintain 150k LOC of legacy JavaScript in a single project.

One of the others was testing furiously.

I wonder how much of this is due to the self-selection of the profession in terms of personalities. Surgery in particular is known to attract Type-A personalities. I witnessed similar attitudes in healthcare and other high-status positions where hubris makes them think they know better...until they have an accident. And even then, there's a strong urge to rationalize the outcome as unavoidable

Visible mistakes generate lawsuits. There used to be more processes, removing them was generally a legal necessity.

It's not just about lawsuits. I've seen cases (hospitals) where checklists drew pushback from doctors because they didn't like being questioned by nurses who noticed them making mistakes. It impinged on their egos. Implementing checklists requires a certain amount of humility that just isn't there in many cases.

They have been using checklists. This news is that they've measured how much harm has been prevented. It's the first country (Scotland) level research.

> The findings, reported in the April 17 British Journal of Surgery, are based on an analysis of 6.8 million operations performed between 2000 and 20014. The Surgical Safety Checklist was introduced in Scotland in 2008 as part of the Scottish Patient Safety Programme, and by 2014 the rate had decreased by 36.6 percent over six years to 0.46 deaths per 100 procedures. Researchers noted that this fall in death rates was not seen in patients who did not have surgery.

I read in this New Yorker article that Spain introduced checklists in 2007. Does anybody know the results of checklists there?

https://www.newyorker.com/magazine/2007/12/10/the-checklist

The medical community uses checklists. They've been using checklists for a while. A number of studies found that they only help for a few months, while they're new.

>I've been getting so upset at the medical community recently

http://www.paulgraham.com/submarine.html

Don't confuse media narratives with what's actually going on in the medical community. It's a sure-fire way to get (a) upset, and (b) entirely misled. Medical science has been a major target for media FUD for ages.

I think part of the reason pilots are so diligent is that it's their own lives on the line too...

I have been in hospitals and seen them going through checklists with my own eyes. I don't think your assumption is completely accurate. Maybe it depends on the health system, the procedure, or the facility.

They have, since 2008. You're right about pace though, unfortunately rolling out change into bureaucracy is painstakingly slow.

I find it very concerning, using a checklist seems like common sense.

The potential benefit of having checklists is enormous, and people's lives are on the line.

Many people rightfully ask

> Why has this not been adopted everywhere _yesterday_?

A book I read a few years ago might have the answer.

_Catastrophic Care: How American Health Care Killed My Father—and How We Can Fix It _ [0]

Here's the description, to evaluate if you want to give it a read:

> In 2007, David Goldhill's father died from a series of infections acquired in a well-regarded New York hospital. The bill was for several hundred thousand dollars--and Medicare paid it.

> These circumstances left Goldhill angry and determined to understand how it was possible that world-class technology and well-trained personnel could result in such simple, inexcusable carelessness--and how a business that failed so miserably could be rewarded with full payment.

> Catastrophic Care is the eye-opening result.

> Goldhill explicates a health-care system that now costs nearly $2.5 trillion annually, bars many from treatment, provides inconsistent quality of care, offers negligible customer service, and in which an estimated 200,000 Americans die each year from errors. Above all, he exposes the fundamental fallacy of our entire system--that Medicare and insurance coverage make care cheaper and improve our health--and suggests a comprehensive new approach that could produce better results at more acceptable costs immediately by giving us, the patients, a real role in the process.

[0] https://www.goodreads.com/book/show/13642523-catastrophic-ca...

edit: formatting

If we had a medicare-for-all system, we could provide some economic discipline by having high deductible plans, even if those plans are completely covered by a government-funded HSA plan of equal value. As long as the HSA could be withdrawn for retirement if unspent.

We also need transparent pricing and reviews. Sites like ZocDoc are trying to fill the niche of something like Yelp but for doctors. There's lots of easy low hanging fruit here.

Essentially they pay for procedures and not for outcomes. Imagine if we compensated plumbers that way.

Here is a link to the actual checklist:

https://apps.who.int/iris/bitstream/handle/10665/44186/97892...

I'm a bit perplexed that something so simple, can reduce post surgical deaths by a third.

Atul Gawande explains in great detail how simple checklists can have big impacts.

For example, why would you need everyone in the room to say their name and what they do?

Simple: everyone is wearing a mask and often surgical scrubs that are the same color. By having everyone say "Hello, my name is Dr. Jones and I'm the anaesthesiologist" you can quickly determine who is the person to direct questions to about the patient being under.

It gets even crazier when you hear stories about doctors going into the wrong operating room (especially at bigger hospitals where there are several ORs). A simple "State who you are and why you are here?" costs very little and helps avoid costly mistakes.

Another example: having a checklist allows a junior person (e.g. a nurse) to challenge more senior people when they make a mistake.

Example without checklist:

Nurse: Dr, I think you forgot to do X.

Dr: I know what I'm doing, don't question me.

Example WITH checklist:

Nurse: Dr, you missed step #4.

Dr: I'm sorry, you are correct. We all agreed that was a necessary step and I missed it.

As have others in sibling threads, highly recommend Gawande's Checklist Manifesto.

Your example depends more on the personality (and mood) of the surgeon than on the existence of a checklist.

Example without checklist: Nurse: Dr, I think you forgot to do X. Dr: Oh, you are right, thanks a lot

Example with checklist : Nurse: Dr, you missed step #4. Dr: I have done this list every day for the past 15 years, I know I ddid not forget anything, don't question me

> Example with checklist : Nurse: Dr, you missed step #4. Dr: I have done this list every day for the past 15 years, I know I ddid not forget anything, don't question me

You're not wrong, but if the hospital policy is to follow checklists, then the doctor overriding it would have to answer some questions afterwards if something were to go wrong.

Presumably a review would occur, and the fact that the checklist was ignored could be used as 'evidence' against the doctor.

You are correct that there are surgeons etc that would reply in the negative no matter what was said.

My understanding is that if the checklist empowers, say, 5% of the nurses to speak up and 5% of surgeons to acknowledge the error that is still a huge net positive over thousands of cases.

My favorite small nudge example is pill bottles vs "blister" packs. Having pills in blister packs has shown to have a significant effect on reducing suicide as it makes it much harder to get the number of pills needed. Yes, some people will still succeed but there is a segment of the target population who will give up after a couple pills.

Nothing will stop someone who's disagreeable, assertive, non-conscientious AND given unchecked status from ignoring a step for capricious reasons.

But medical school is going to heavily select for conscientiousness (a personality trait that checklists work with), and also checklists are essentially another authority in the room.

So, yes, you could potentially have discussions over whether or not something has actually been done. But you aren't going to have discussions about whether it should be.

The solution to that is to have people have proper uniforms. Eg surgeons/doctors/nurses wear different color scrubs & hats or insignia for rank. It was like this in the old days.

A lot of airline-style cockpit resource management is being adapted for operating theatres, and it is a good thing.

If a junior person thinks that a senior person is about to make a terrible mistake, then the word "Stop!" should be used, along with the reason. That word will often make even the most arrogant person pause and think about what they are doing.

Humans can hold about 5-7 things in working memory. You'll note there are 22 items on that list + the headings of when to do them.

Expertise and practice makes some of those things automatic, but not enough to reduce it all below 5-7. Further, in any surgery there will be other things going on that require cognitive attention, decreasing capacity for other things.

Everything you can do to reduce cognitive overhead makes a process smoother.

I teach the LSAT. One section logic games (officially, analytical reasoning) tests precisely this cognitive load. Students must work with 4-6 rules + what the situation calls for on question.

The rules are impossibly simple. But, in the heat of things, students just aren't capable of working with that many items unless they create a structure using diagrams. And even seemingly tiny efficiencies have an outside effect on speed and correctness.

Don't forget that these surgeons are often tired busy and stressed, three factors that worsen performance. Having a clear list that says "do this now dummy!" massively helps keep you on track even when you're a wreck.

A lot of the time, people ignore over small, simple things because they either assume someone else already took care of it or that it's such an obvious thing that how could anyone not notice. The checklist forces you to actually look up and see that the extra blood needed for the surgery didn't show up or that one of the surgeons present is actually supposed to be in another OR.

It's like help desk asking you if it's plugged in. You may think of yourself as a technical person and that the problem is more complex like the driver isn't loaded or the monitor isn't properly configured but the problem could just be that you forgot to plug the video cable in. Just having those basic checks occur before anything can go wrong makes it so that when things do go wrong, time doesn't need to be wasted on going over the simple stuff or even worse, forgetting about the simple stuff and going down the wrong route.

In any profession most practitioners are bad at what they do. There's nothing magical about medicine that exempts that profession from this rule. If your mechanic can forget to refill the oil in your engine there's no reason to believe that your surgeon won't leave a knife in your abdomen. There will be by necessity bottom-tier doctors and the checklist helps bottom-tier doctors stop killing people.

Not just bottom tier... humans are very good at making simple mistakes. It's one of the things we do best. A lot of times the people who are rated as "good" or "great" are rated that way because the make fewer mistakes, not because of perfection.

I'm not. A clinician is a human, and as a human, they can be distracted, tired, hungry, or any number of things that can reduce their cognition leading them to miss something. A checklist reduces cognitive overhead and provides accountability (no way a clinician would remember if they did or didn't do a particular action days or weeks or months after the fact).

>I'm a bit perplexed that something so simple, can reduce post surgical deaths by a third.

Because it didn't. It attributes the entirety of a decade long decline to the check list, which is obviously nonsense. I'm not saying that checklists aren't good, but they're not miracle workers.

They didn't just measure the difference and call it a day.

https://onlinelibrary.wiley.com/doi/full/10.1002/bjs.11151

>The Scottish Patient Safety Programme (SPSP) is a national initiative which aims to improve in‐hospital mortality rates in Scotland. The SPSP was established in 2008 and had perioperative management, including implementation of the WHO surgical checklist, as one of its four key initial workstreams. This programme offered a systematic approach to improve patient safety across all hospitals in the country26.

>After testing, review and feedback from health boards across Scotland, the surgical checklist was included as one of the ten Patient Safety Essentials to be implemented across all health boards in Scotland37. The surgical checklist was not a stand‐alone intervention. It was, however, the only Patient Safety Essential that targeted surgical patients specifically during the interval studied37. Thus, the addition of the checklist to the other parameters within the SPSP may have contributed to the improvement in results observed in the present study.

>It is acknowledged that attributing causal links to the findings in population‐wide data set analysis is not possible.

What you said they didn't do is kind of exactly what they did. Yes, there is some attempts at hand waving, but it's silly to boil down the success of a large and multi pronged program to a simple checklist.

https://onlinelibrary.wiley.com/doi/full/10.1002/bjs.11151

Here's a link to the study.

Please point out the parts of it that you find to be scientifically failing.

There's a valid point to be made that the original article implies a greater causal link than the study, but that isn't the study's fault, and it doesn't actually diminish the effect of the checklist in the process. Poor reporting on science is always a problem, and journalists typically use layperson phrasing in order to make the information more consumable.

"The Checklist Manifesto" by Dr Atul Gawande details how resistant to change Medical Professionals can be to procedure. I thought it was hyperbole until I sat in on a certification training for a hospital group and the toxic cloud of chatter about not changing anything because it didn't make a difference was jaw-dropping.

The article (really a blurb) mentions Atul Gawande, he's written extensively and accessibly on how to improve healthcare both cost and quality. I can't recommend his writing enough, especially his New Yorker articles where he tackles subjects like unnecessary care, electronic health records, doctor training, etc.

Article on checklists in the New Yorker

https://www.newyorker.com/magazine/2007/12/10/the-checklist

Given the number of surgeries/year in Scotland (2009/2010 20,048) [1] the checklist saved:

Death rate after fix: 0.46% Number of deaths after:93

Death rate before fix: 0.46/(1-0.37) = 0.73% Number of deaths before: 147

Number of lives saved per year: 54.

[1] https://academic.oup.com/bja/article/119/2/249/4049141

Checklists are the reason that California has 4.5 maternal deaths per 100k live births, while USA as a whole has 26.4. [0] If hospitals cared about this sort of thing, there wouldn't have to be state regulations for this. If states besides California cared about this sort of thing, they'd have the regulations too.

[0] https://www.usatoday.com/deadly-deliveries/interactive/how-h...

It would be interesting to see the implementation of an Alexa/Google' smart speaker & tablet system to provide support to doctors & nurses. For example:

Doctor - "Smith, please provide checklist for Septal Myectomy"

Smith - "Confirming list for Septal Myectomy?"

Doctor - "Yes"

(Smith raises first point)

Doctor -"Check"

(Smith raises other points until the end of the list)

Smith - "You have completed the checklist for Septal Myectomy, please review it on the screen if you so desire. Is there anything I can help you with?"

Doctor - "Thanks Smith, no need for anything else"

I would be eager to support a project that would provide this kind of support to doctors and other professionals.

I'm not convinced about using a lot of checklists. I have no doubt when checklists first come in everyone follows them and there are some measurable improvements.

The problem I have twofold. A few years down the road will people still really follow the checklists religiously, or quickly just fill out the boxes.

The second part is people's jobs get dumbed down by this, I'm sure we've been in some situation where there is a structured system which you have no control, you just fill out forms, its disempowering so you learn not to think, just do your part of the system and hope it turns out OK. Its where bureaucracy and red tape starts. I've quit jobs like that because I found it demoralizing.

Will be interesting if there was a follow up 5 years later.

EDIT: Didn't you get the memo about your TPS reports? That is what I'm trying to avoid.

Its where bureaucracy and red tape starts.

What people call bureaucracy is process that they follow without knowing why it's there. Every single rule in a business is there because something went wrong, and someone didn't want it to happen again.

The answer to bureaucracy is transparency. If you explain why a rule has to be followed people don't mind that there's a rule.

(You also have to regularly review the rules and get rid of ones that don't make sense any more, but that's much less common that you'd think.)

It must become a culture. In Japan, there's a culture in the public transport business (trains etc) of 'point and say' where each responsible crew member points at a target e.g. safe door open zone marked on the pavement, and says out loud that its correct or not. Its a physical reenactment of a checklist? Anyway it becomes second nature if its a physical act, not a check-the-box-on-a-form thing. So that's how they manage it not getting skipped/becoming just paperwork.

The checklist was given elsewhere in the thread: https://apps.who.int/iris/bitstream/handle/10665/44186/97892... it really doesn't strike me as something that dumbs down the job...

"dumbs down" is such a loaded phrase, but I'd argue that it's accurate here and most other places it's used. Anything that makes something easier is dumbing it down.

However, I want it "dumbed down". I want it to be easier to prevent mistakes. I want smart people to use more of their brainpower on things that can't be solved by some words and boxes on paper. If the surgeon is thinking about the surgery instead of what he might have forgotten about the pre-op, that's good, IMO.

> If the surgeon is thinking about the surgery instead of what he might have forgotten about the pre-op, that's good, IMO.

Agreed. The only issue is that if the surgeon isn't thinking about the surgery because he's still doing all the routine paperwork.

I create short-lived checklists all the time. For an up-coming food shopping outing, or a to-do list for the weekend.

My favourite ones are for vacations... My wife and I will be taking our son (who will be 5 months old at the time) on his first trip that will require long haul flights (Australia - Vietnam - UK) so I'm currently working on a checklist for what to have in our hand luggage, and a separate one for the hold luggage. For me, it's part of the looking-forward aspect to such a trip, plus there are lots of things that we really don't want to forget, or run out of.

And anyone who's scuba dived will be familiar with the three item checklist that forms part of the pre-dive "buddy check".

* B A R (buoyancy, air, releases) in the UK

* A B C (air, buoyancy, clips) in the US and probably elsewhere

A potential life saver!

For 30 years, every place I've gone to, I've implemented release process and release day checklists because they didn't exist. I've experienced push back every time: "We haven't needed these before.". At all of these places, release issues were always "bad luck". All of my teams have acknowledged these were awesome and reduced release day stress.

I completely understand why this took effort to get implemented and why it seems obvious in retrospect.

Do you have examples or a blog post that covers some of the checklist items? I find this interesting.

Add to the checklist: Can the patient survive the trip home? Based on a true story.

The saga of how this checklist came into existence is detailed in Dr. Gawande's book The Checklist Manifesto.

Or the much shorter article https://www.newyorker.com/magazine/2007/12/10/the-checklist

If I remember correctly, they had similar results (>30% improvements) with their pilot study in Michigan

Should you want to know more about checklists, here's the very Atul Gawande https://youtu.be/dfl8Xt8W09A

Freakonomics Radio had Dr. Atul Gawande on a year ago (April 2018) and discussed medical checklists among other things.

http://freakonomics.com/podcast/atul-gawande/

I started using a checklist for my motorcycle track days a few years ago when I almost forgot the key to my bike. I remembered as I was pulling out of the driveway. Now I've got a thorough checklist, and a track bike that doesn't use a key.

I've seen a huge personal impact adopting principles from David Allen's Getting Things Done methodology, which in some ways is simply a checklist management system. As others have mentioned, it's not just preventing me from forgetting to do things. Capturing my thoughts and intentions externally reduces stress and frees my mind to have more new thoughts. My creativity has skyrocketed since I started writing down every project/product idea I have, and adding to them over time. Currently using Trello (which works great for this), but eventually I'd like to switch to something open source or make my own system tailored to my needs.

I used to use trello too, but I switched to notion, which is more free-form and let's you organize things how you want. Sounds like what you might be looking for.

I've seen it mentioned. I'll take a look, thanks

A great book on this subject is The Checklist Manifesto [0]. An interesting point made in the book is that checklists help to correct the subtle psychological problems that occur in an operating theatre. Without a checklist a nurse who sees a potential problem might be hesitant to halt the procedure when the surgeon is ready to start. But with a checklist the surgeon must get explicit permission to begin from the nurse who is performing the checklist.

[0] https://www.amazon.com/Checklist-Manifesto-How-Things-Right/...

It is fantastic to see this pan out in real life. I read the checklist manifesto by Atul Gawande who helped to author the WHO checklist. It really one of these mind expanding books that everyone should read. I have seen below comments that ask why checklists are not standard even though they were pivotal in reducing flight accidents. The reason is that knowledge is often siloed, and people tend to overestimate themselves. How many checklists are you using at work? If none, ask yourself why, and if they could be helpful.

The book also talks about the design of checklists which is not trivial at all.

The article is short so doesn't really delve into what happens after those deaths - specifically investigation into cause or the legal ramifications.

I was hoping to get that info because the first thing that popped into my mind was that people are/were apparently dying due to unnecessary reasons if a simple checklist prevents 37% of surgical deaths. If that's the case, the only way I could imagine classifying those deaths would be "gross negligence" and therefore not subject to the protections of the legal agreements you sign before surgery.

I can't talk about Scotland because they have a devolved system and I have no idea how it works up there.

I can talk a little bit about England.

There are two main ALBs (arms length bodies) that will be involved: NHS Resoulation (the organisation that handles legal cases) and NHS Improvement (the organisation that handles QI work). NHS England and NHS Improvement are merging and I don't know what the new name will be. NHS Resolution used to be called NHS Litigation Authority.

https://resolution.nhs.uk/

https://improvement.nhs.uk/

The information that NHSi has about "Just Culture" is here: https://improvement.nhs.uk/resources/just-culture-guide/

If you have a look at this flow-chart you can see that they're trying to find out if an incident that caused harm was deliberate, grossly negligent, caused by wider system failings, etc. https://improvement.nhs.uk/documents/2490/NHS_0690_IC_A5_web...

If you have a look at NHS Resolution's page about learning from harm you can see that they're keen for healthcare professionals to 1) Say sorry, 2) explain in full what went wrong 3) Explain how that's going to be prevented in future. https://resolution.nhs.uk/services/safety-and-learning/

This expands upon a legal duty of HCPs and NHS Trusts in England: the Duty of Candour.

Here's the advice for doctors: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for...

And nurses: https://www.nmc.org.uk/standards/guidance/the-professional-d...

And other registered healthcare professionals: https://www.hcpc-uk.org/assets/documents/10003f72enc07-dutyo...

And organisations: https://www.cqc.org.uk/guidance-providers/regulations-enforc...

If a patient does decide to sue I think they can only recoup their actual losses. I think we don't have punitive damages in England.

I am an anaesthetia doctor. There is, in fact, only mixed evidence of checklists actually helping in various health systems around the world. At a national level, Scotland began using checklists, but the whole health system and population is always in flux, so attribution of such a big change just to checklists is bold. It may also be that checklists do (temporarily?) improve broken or highly resource constrained peri-operative care: but this leaves open the question as to whether correcting underlying staff/morale/equipment/logistic problems would have, or should, play a role.

Checklists I have seen used during my career are often rushed through, with more time usually being spent appropriate to the complexity of a situation. Local culture will strongly impinge on effectiveness of (yet another?) checklist. The safety culture in medicine is improving dramatically, but there is tension between protocolizing everything into checklists, and individualizing care to each patient. AI will be part of the solution to this.

An important checklist commonality in medicine is the request that _anyone_ should speak up if they think something is wrong. In analyzing situations where patients were harmed, e.g. wrong side surgery, it is common to hear that someone, a nurse, a technician, did notice, but was not empowered to speak up. As a doctor, I am used to the power to speak up and act, but I value others' eyes in many situations. More complex and highly dynamic medical situations will always require the attention, knowledge and skill of those involved.

The checklist seems to be here: https://www.who.int/patientsafety/topics/safe-surgery/checkl...

As a software engineer, I'd hope this was done in software, where it could be trivially filled in by multiple people, checked across the organisation, not go missing or get drinks spilled on, etc.

Knowing the NHS south of the border, I assume it's not.

Papers probably easier - these NHS software projects always end up disasters

Checklists are great; checklist bureaucracy not so much. Sometimes such bureaucracy is necessary.

For example when you are flying a cesnna 172 from the nineteen sixties, you are basically flying a glorified lawn mower. It has procedures for starting up. Not following those will lead to disasters like your engine quitting, or worse self destroying. Hence a lot of checklists in aviation tend to be about engine management. These are important, they keep you alive and save you from high maintenance cost and accidents.

Cars used to be similarly complicated but these days you simply turn them on and drive. Likewise, checklists for modern airplanes that have elaborate engine management software tend to be a lot shorter and also focus more on other things (check the amount of fuel).

Checklist are easy to automate for a lot of use cases and doing so increases safety because computers are a lot better at checking lots of things than we are. After checklists become part of your process and increase your effectiveness, automating them can increase your efficiency.

The analogy in software engineering is replacing release processes with CI and CD. It used to be that people were enduring such things as commit freezes, meetings about blocking issues, go/no-go decisions, etc. This could last for weeks or months. Also the process of actually creating release artifacts and publishing those was a lot of work. These days, some systems release whenever a change is merged to a particular branch. All the checks around this are automated (tests pass). The entire process of releasing can be automated.

Checklists are the foundation of a proper quality system even in software development. I manage a team of programmers that develops a regulated product in healthcare (Class 2 Medical Device) - we use checklists extensively throughout the development cycle, in release planning, release kick-off, feature kick-off, in design reviews, in risk/hazard meetings, to track in-house and external validation, and post-release activities.

I'm surprised how little checklists are used in software development. In our application, checklists track even simple things. Suppose you're adding some new feature we have a checklist that tracks related activities such as:

- Does it need a toolbar button?

- Does it need a keyboard/mouse input biding?

- If so did you add a keyboard binding to the default configuration list?

- If so did you add the binding information to the user help file.

- Should it be exposed in Mobile Native App?

- Should it be exposed in Mobile HTML App?

- Should it be exposed in HTML App?

- Was the button label localized?

- Was the identifier added to the toolbar mask list?

- Does it need to be added to the context menu list?

- Does the behaviour need to work with Reset?

- Does the behaviour needs to work in a collaborative session?

- Does the button need a feature flag?

etc.

It's a quick list that we can get through during feature kick-off before unpacking commercial requirements and starting a sprint and during final validation to make sure al the i's are dotted and t's crossed.

Does this include the new(ish) timeout procedure? Docs and nurses will take a beat before surgery to say the patients name, what the procedure is and I think one or two other very basic things. This has been done for a few years now in the USA and I find it fascinating. So basic in such a sophisticated space and I have heard it has had a profound impact on patient safety.

Any surgical staff around to tell us more?

I'm not surgical staff. The checklist does include this discussion phase. Here's the English version: https://improvement.nhs.uk/documents/450/SFHFT_-_Invasive_Pr...

I love prepared checklists! It's the ultimate productivity hack for me. I spend time upfront preparing the list, and then I go into auto-pilot everytime I use it. No stress, no cognitive load, no questioning whether you've forgotten something.

I use one for travel (did I pack a neck pillow?), night-time (did I pack my gym clothes for tomorrow?), and recently for the gym (what workouts am I doing today?)

Several times in the discussions here I read about the checklist in question: but these are obvious items, why do they need to be checked? I think that is the very point of check lists: not to miss actions, because they seem to be trivial/obvious. Be it because the stress levels are high or because one is focussed on the "real problem at hand". In a sense, the more intelligent/capable/experienced you are, the more you are at risk of missing something as you are focussed on the big picture.

As a software developer, while not having checklists as printable documents, I highly appreciate the checklist approach. This can take several shapes. When doing a software release, I perform the necessary steps always in the same order. This makes it easier to correctly perform everything needed. And of course I check the result of every step for the expected result.

Checklist-like approaches can be even very helpful when debugging issues. I often enough get to resolve "the software doesn't work" like issues. And of course, there is no obvious reason, like a meaningful error message or stack trace. To debug this kind of issues, I start with simple and trivial things. While not a static list - the cases are too varying for that - I tend to start with asking and checking very basic questions, like: is there enough free disk space? Repeating the steps which, according to the bug reporter, lead to the issue. At each action taken, verify that any observeable result matches the expectation, even if those actions are not close to the bug. This approach has usually two outcomes. Either a very trivial explanation for the problem is found, because some seemingly trivial step fails, or at least, I know, that all the things tested are note related to the problem. Excluding a wide range of possible problems can be surprisingly helpful in narrowing down the actual problem.

The "checklist manifesto" is a staple in American Healthcare... And when I was consulting on hospital builds and go-live... this was the methodology we used.

https://www.amazon.com/Checklist-Manifesto-How-Things-Right-...

Any recommendations for good apps for routine checklists (i.e. repeated daily)? (preferably cross-platform and without subscriptions.)

Before checking in code:

* have the unit tests been built and run?

* have I reviewed all changes and removed commented out code, tidied up?

Edit: oh, you meant apps. I read your comment as asking for good items for checklists.

Checklists are probably good but looking at the actual paper[0] I don't think we can conclude "a third" with much confidence. The mortality rate for surgeries was already declining--the argument is that it declined faster during the implementation period (Fig 2; 2008-2010). Also it appears the types of admissions changed a lot during the same period based on the stark difference between Fig 1 (unadjusted) and Fig 2 (adjusted).

I'm surprised that the researchers didn't use better data or variation (e.g., hospital-level mortality or the timing of the rollout) to strengthen the case. So much can be lurking beneath annual country averages...

[0]: https://onlinelibrary.wiley.com/doi/full/10.1002/bjs.11151

The study:

https://onlinelibrary.wiley.com/doi/full/10.1002/bjs.11151

I'm an aviation enthusiast and have started developing check-list for maintainers of the software I develop at work. I hope it will reduce cognitive stress in situations of on-call.

Doesn't this indicate some sort of malpractice in Scotland? I would think that forgetting important procedures leading to death is the definition of malpractice.

I'm not really sure what your point is. Ultimately, any kind of negligent behaviour would be "malpractice", but that's not something that can be completely eliminated. Mistakes always happen, regardless of care or attention paid; it seems like the focus should be to develop systems which can minimise their occurrence, minimise the severity of them if they do occur, and help to provide information that can reduce recurrence.

I find the approach of things like rail and air accident investigations to be really useful. The goal for the investigation of any accident should not be about apportioning blame, but understanding why accidents happen and how their occurrence can be effectively reduced or eliminated.

The English NHS was dealing with about one million patients every 36 hours. https://www.england.nhs.uk/ They were doing over 8 million surgeries per year when the checklist was introduced.

For 2016/2017 the summary of "never events" is here: https://improvement.nhs.uk/documents/2347/Never_Events_1_Apr...

There were 189 wrong site surgeries, and 114 retained foreign object post surgery.

That's not good enough, but it's not terrible.

The month by month data is here: https://improvement.nhs.uk/resources/never-events-data/

I have a comment about the regulatory framework (in England) here: https://news.ycombinator.com/item?id=19683366

Going one step further, the Japanese train industry has a concept called "pointing and calling" where they literally point at the thing that should be complete and call out the task. It noticeably improves completion of these tasks.

https://en.wikipedia.org/wiki/Pointing_and_calling

I can recommend the book Black Box Thinking [1] by Matthew Syed. It covers how not only checklists but also the learning culture that produced them can be applied to other industries and areas.

[1] https://www.amazon.co.uk/Black-Box-Thinking-Surprising-Succe...

This makes me think of Charlie Munger's insistence on checklists: https://www.amazon.com/Poor-Charlies-Almanack-Charles-Expand...

Checklists: boring and tedious!

To catch errors, I started double-checking math problems, by generating a checklist on the spot.

But I also made fewer errors, and developed more intuition. I think checking itself was a deeper practice; and also gave an overview of the task (less cluttered by detail) that helped me make connections at a higher level.

Checklists: insightful and tedious!

Atul Gawande wrote a fantastic book[0] on the topic.

[0]: https://www.amazon.com/Checklist-Manifesto-How-Things-Right-...

Perhaps they could pick up the Japanese train drivers pointing and calling:

https://www.youtube.com/watch?v=9LmdUz3rOQU

Referring to things in multiple ways is supposed to have a more thorough confirmation, although not a good idea to point whilst wielding a scalpel.

A few others have mentioned it, but this reminds me of shisa kanko, the pointing-and-calling system used in Japan.

https://www.atlasobscura.com/articles/pointing-and-calling-j...

For people interested in this, I strongly recommend reading the Checklist Manifesto https://en.wikipedia.org/wiki/The_Checklist_Manifesto

A checklist is a practical tool to document processes.

Banana boxes are fantastic. Even so, checklists help me audit my adventure inventory to make sure I have everything I need before I set off. I even use checklists for making sure the apartment I'm about to rent has everything in order. Things like check under the sink for leakages.

Does anyone else think that a nearly 1 in 200 chance of dying following surgery is very high? I'm not sure I'd want surgery for a non-life threatening condition if the chance of death is that high.

I suspect your chances to die from surgery for a non-life threatening condition may be a lot lower than 1 in 200, while your chances of dying if you are 80 years old, on the brink of death, with multiple different conditions at the same time, and having difficult surgery.

This reminds me of the Japanese railway employees pointing at things.

https://www.youtube.com/watch?v=9LmdUz3rOQU

That's terrifying. Thousands and thousands of lives have been lost simply because we were forgetting to do the right things? And we created a process to fix this in... 2019?

The process was introduced in 2008.

This news is that we've now run research across an entire country (Scotland) for the surgery carried out between 2000 to 2012 to find out how much harm has been prevented.

We had death by Powerpoint recently on HN. Is this life by Excel?

Great interview with Dr. Gawande here: https://fs.blog/atul-gawande/

can anyone comment about applying this "checklist process" to software development? has anyone used it to help with debugging, testing, merging, etc.?

I've used it in situations where writing automated tests would have been too difficult compared to running through a checklist each time. I made a web game based on a variant of Chess, and I would run through the checklist before I committed to verify I hadn't broken anything. https://gist.github.com/CGamesPlay/1b3e150c5448c51fd6ea71ea6...

Automated tests are a checklist for when you refactor code: "The code is supposed to do A, B, and C. Does it still do those things?" If you practice TDD, the tests are just-in-time checklists for your implementation work.

The problem with relying on tests written after the implementation is that the checklist might be incomplete. If your checklist is incomplete, then you can't rely on it. Of course, even a highly disciplined practitioner of TDD cannot produce a test suite that is guaranteed to be complete and correct, but there is an enormous difference between a checklist that is adequate 50 % of the time and one that is adequate 95 % of the time.

Look for ways to avoid simply "going through the motions". Checklists (including TDD) are about avoiding making mistakes, not merely about noticing when you do make mistakes.

This is how fast food franchises work and is why you get a consistent experience from them all. All the processes are documented and checklists abound.

Checklists are great. Less cognitive load having to recall things. I use Trello boards for maintaining my personal checklists. Recommend it.

I lived in Scotland for a decade or so. On the surface, the provision of healthcare seemed good, and the media constantly tells you it is, but it tended to fall apart once you needed it for anything serious.

I heard of the experiences from countless others and, sadly, encountered it myself. As the patient, even though you are paying for the service through high taxes, you are not seen as the customer. This leads to a certain sense, when you do need a medical service, that they are doing you a favor, that you are somehow the recipient of charity and should be grateful for what you get.

Decisions about what medicines or treatments are available are often political, with certain high-profile conditions sucking up scarce resources at the expense of others. The focus is very much on managing public opinion.

There are many situations in which cost considerations have a horrific impact on lives. For instance, if there is a medicine which can prevent you losing your sight, but it is expensive, you will be offered it only for your second eye after you have lost sight in your first - the reasoning being that it is only worth spending that much money to prevent total blindness, but sight in one eye is enough.

If you think that your high taxes mean that your healthcare needs are covered, think again.

There is also a deep-rooted coverup culture that circles the wagons around bad doctors and poor processes. In my case, a ridiculous misdiagnosis had a real impact on my life for over a year. The other healthcare professional only came clean about it after the lead doctor had retired.

Again, you are not seen as the customer, as the one paying all their wages, so, you should just shut up and be grateful for what you get.

I often laugh when I hear inexperienced American talk about how much better the health system is in the UK. Sure, health insurance is expensive, but the actual healthcare is leagues ahead of anything available via any sort of national health service. Being recognized as the customer, with real rights, is of pivotal importance in receiving the care you need, when you need it.

In fact, you often come across UK citizens with a rose-tinted view of the National Health Service, but such opinions tend to change rapidly once you actually need something more than an occasional General Practitioners appointment. The whole thing is a cruel joke.

> Being recognized as the customer, with real rights, is of pivotal importance in receiving the care you need, when you need it.

Except if your poor though right? Isn't that really the case?

In the UK we don't tend to ignore kids broken bones if they have poor parents. No one goes bankrupt and ends up homeless for contracting an illness, or having an accident at work.

We also spend less on our taxes towards the NHS than Americans spend on their Medicare - and then you have to pay for private 'health care' insurance on top, including all of the 'co pays' and whatever. It's a system that's rigged against you. For the rich, by the rich, to make the rich richer.

Even if the top 1% of private healthcare is better in the USA, you're ignoring the 99% of healthcare that isn't.

Most Americans just can't see the simple fact - many many other countries are better at this than you are. This is a solved problem in many other developed countries.

Universal healthcare simply benefits everyone in society, and does so purley for the common good.

> In the UK we don't tend to ignore kids broken bones if they have poor parents. No one goes bankrupt and ends up homeless for contracting an illness, or having an accident at work.

Kids with broken bones are at the easy end of the scale. Most people, before they have experienced serious, complicated, expensive health issues, have a series of relatively positive experiences with the NHS in which they present with a minor issue that is dealt with by in a satisfactory manner. The system is optimized for that. This maintains the illusion that, through your taxes, your health requirements are "covered".

This falls apart once you present with something more complicated. You might be surprised at the extent to which people in the UK are pretty much abandoned when they hit a certain point. I know of many cases in which people had to find the money, somewhere, to buy vital treatment that the NHS was not willing to allocate. This is no less brutal than what happens to the uninsured in the US ... but ... the big difference is that UK residents are under the delusion that they do not need to worry.

Again, my argument is not that the NHS is bad, or evil, or that it does not sometimes do a good job. What I am saying is that, over your lifetime as a whole, it costs more than good health insurance would while letting you down badly when, inevitably, you encounter more serious problems.

The best way to help the poor is to improve the economy. A massive, complicated tax system makes it particularly hard to hire people at the low-end of the skill range. It is simply not worth it, and this will become increasingly evident as workers continue to be replaced by technology.

The UK has ended up with a multi-generational unemployed class who are under the illusion that everything will be taken care of "from cradle to grave". Their personal agency has been almost entirely removed. Alcoholism, obesity, diabetes and depression are at epidemic levels among the unemployed. We have created the perfect storm and it is the poor who will bear the brunt of that.

> I often laugh when I hear inexperienced American talk about how much better the health system is in the UK. Sure, health insurance is expensive, but the actual healthcare is leagues ahead of anything available via any sort of national health service

Exactly the same private healthcare is available to you in Scotland, if you chose to pay for it.

Yes, it is available, but the high levels of taxation - not just income tax but, also, a 20% tax on purchases - means that most families simply cannot afford that.

My argument is that people are _already_ paying but in a mandatory, indirect way, that removes their power as consumers and creates a situation in which the health services' prerogatives often differ from those of the patients.

while i don't contest the usefulnes of checklists ...

"... some of the largest population-wide reductions in surgical deaths ..."

_reductions_. but how does it compare using absolute rates? it's usually easy to achieve good numbers when the baseline is sub-par (diminishing returns).

In France, a surgery checklist is available since 2008 or 2009 but alas, it's not mandatory.

2019, age of AI/ML .. checklist is the most impactful health improvement. Interesting

Dr. Gawande’s book “The Checklist Manifesto” can be life changing if properly applied.

Not sure why people don’t do checklists for everything. Professionally and personally.

Cut down post-surgical deaths by using this one weird trick.

I have Dr. Gwande's book for years now.

Is this checklist used in the United States?

Didn't read article - [check]

I instituted checklists across team process and can't recommend it enough. Our pull request process reduced subjectiveness in PRs and approval time. It also seemed to improve the quality of what got through the PR process. We also had them for deploy process, sprint planning, and a few other domain specific areas. We had other teams give input, which helped with compliance challenges like GDPR and COPPA.

What is the list?

Here's the actual 19-point checklist in English[0, pdf]

and other languages[1]

[0]: https://apps.who.int/iris/bitstream/handle/10665/44186/97892...

[1]: https://www.who.int/patientsafety/topics/safe-surgery/checkl...

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