Power of Ticking Small Boxes

"How can you guys commit such a dumb mistake?" lashed out our boss, a 30-year veteran in the air-conditioning industry. Avoiding eye contact with him, all of us—the engineers with graduate and postgraduate degrees--were looking at the round meeting table. On the table lay a thick black file with the label "Design calculations: Jewelry Showroom Air-conditioning Project." Though the project was declared "finished" three months back, it now featured on the top of our boss's priority list for a reason that irritated him the most: Our filthy rich client had refused to pay us any money.

Countering our payment claims, the client, the top jewelers in the city, had been complaining that it was too warm and uncomfortable inside the showroom instead of being cool and comfortable.

The boss’s fury was not unexpected, for our internal review of the air-conditioning system had revealed a significant design mistake. Basically, the design engineer had grossly underestimated the heat gains due to excessive lighting, a normal feature for glittering jewelry showrooms. Like a golf ball falls several hundred meters away from the target if you hit it only few degrees off the right trajectory, this bug had led to the under-sizing of the cooling equipment--and eventually a dissatisfied client and no payment.

Eventually, the monologue ended, but the two words hurled by the boss at the beginning stuck in my head even though I had joined this company as a fresher from the college and knew little about designing air-conditioning systems, leave alone committing design mistakes. 

“Dumb mistakes.”

What amazes me is that almost 30 years later (the above incident happened in 1991), those two words haven’t deserted me. And for a good reason...during the journey since then, I have seen many more (some by me and some by others) mistakes, which on hindsight look embarrassingly dumb. 

Mistakes—big and small--continue to plague engineering projects: equipment installed in a location where it can’t be accessed for servicing, under-sizing or over-sizing of equipment, wrong connections in piping, ducts and control cables, wrong sequence of components in a pipeline, fans installed in reverse direction and so on. I have even seen people discovering the sizes of the rooms smaller than the drawings after completing the construction. 

When you look at such incidents and also the cumulative experience of the people managing these things, you can’t help but wonder, “How could such mistakes happen with so many experienced people—so-called experts--around?” And more importantly, "Is there a smart cure to this problem of dumb mistakes?"

To understand this paradox and a potential solution, let’s look at the world where experts are supposed to save lives and yet avoidable mistakes do cost lives. 

Dumb mistakes, disabilities and death

For a patient, surgery is often the last resort in the treatment, but in 2006, the World Health Organization (WHO) was facing a reverse problem: Unsafe surgical practices were harming the patients. Of 230 million surgeries performed worldwide annually (2004), at least seven million people a year were left disabled and at least one million dead. Instead of being a cure, an unacceptable proportion of surgeries had turned into a disability and death trap for the patients.

The initial observations showed the harm to patients came from avoidable slippages like, not marking the body part to be operated, not taking care of a patient’s allergies, not administering antibiotic on time (should be within 60 minutes of a surgery), not labeling the specimens correctly and so on.

Like the engineering field, the medical field was not immune to dumb mistakes.

Cure for fatal dumbness

Determined to protect the patients, in 2007 WHO formed a task force of doctors, anesthesiologists, nurses and patients. Considering that some 2500 types of surgeries were performed worldwide—from brain biopsies to toe amputations, pacemaker insertions to spleen extractions, appendectomies to kidney transplants--a truly innovative solution was required.

What could make surgeries safer--worldwide? 

Searching the answers, the task force considered options like training doctors and nurses in safe surgical practices, issuing a set of guidelines and even paying incentives for performing surgeries safely. Besides moving the needle on surgical safety, the solution had to be cost-effective and practical, regardless of where the surgery was performed--from the US to Europe to India to Africa.

Unfortunately, none of the options looked feasible. 

Smart cure for dumb mistakes

Not giving up and trying to learn from other fields, the task force observed how the aviation sector depended heavily on written instructions and checks to avoid fatalities due to human errors. That was their breakthrough, leading them to a solution that looked too simple for a complex global health problem: issue a surgical-safety checklist. 

The checklist included nineteen checks: seven before anesthesia, seven more checks before incision and final five checks before wheeling out the patient from the operation theatre. The checks included precautions that everyone knew were necessary for patients’ safety but often ignored: confirming patient’s identity, marking the site of surgery on the body, confirming that antibiotic was given on time, accounting for all instruments, sponges and needles after the surgery and so on.

Against the skepticism of many who wondered how a piece of paper with a bunch of little checks and boxes could improve surgical safety, the team went ahead with a trial. Did it work? 

Overcoming human fallibility

When the checklist was implemented in eight hospitals around the globe under a pilot testing program, over the next three months, the rate of major surgical complications fell by 36 percent and deaths fell by 47 percent. Infections due to unsafe surgical practices itself fell by nearly half. The checklist nudged the well-qualified doctor and nurses to be disciplined, and take precautions that were often overlooked due to the time and complexity pressures. 

The human ingenuity to create a simple tool—a checklist—had helped overcome the human fallibility in complex situations. 

Checklist: Mapping the stepping stones

My love affair with checklists began after I read the book “The Checklist Manifesto” by Dr. Atul Gawande, an American surgeon, who was also the leader of the WHO task force that issued the surgical safety checklist. 

Drawing on decades of surgical practice, he stresses that in complex environments, experts operate against two challenges: First, the limitations of human memory, especially in the face of distractions. And second, experts can often lull ourselves into skipping precautionary steps. "Checklists seem to provide protection against such failures," writes Dr. Gawande.

Looking back, I believe we could have avoided the design mistake in that unforgettable jewelry showroom project if our team had used a checklist to systematically check all the design assumptions. But we relied on our experience and memory--getting almost everything right, except one small detail that made a big difference in the end.

Not that we don't know checklists; sometimes we do use them but only to complete "paperwork" formalities. Unfortunately, we underestimate its power to augment our expertise and memory, show us the potential pitfalls and pave the way to right outcomes. If a checklist can save people from disabilities and deaths, shouldn't we recognize its true power?

Think of an instance when you or someone around you slipped on something that should have been checked, leading to painful consequences. Could it have been avoided with a checklist? Think of what worries you going forward in your work. What could go wrong? Can a checklist help?

Of course, a checklist is not a panacea; mistakes--big or small--may still happen, but it can save us from the risk of really dumb ones. In the end, using a checklist is like mapping the stepping stones before crossing a fast-flowing deep river. You don't want to miss even a single stone!

=======Thanks for reading this long article!======

NOTES:

1. A short video on how a checklist can help to improve the quality of Standard Operating Procedures (SOPs): Writing High-Quality SOPs
2. For more on checklists, read the book "The Checklist Manifesto" by Atul Gawande.
3. Bad checklists are vague, too long, hard to use and impractical. An effective checklist is short, simple, clear and practical.
4. Checklist is a means to an end but not the end in itself. Checklist itself can’t fly an airplane or carry out a surgery. But when used effectively, it has prevented airplanes from crashing and patients from getting killed.