We’re obsessed in medicine with having great components—the best drugs, the best devices, the best specialists—but pay little attention to how to make them fit together well. Berwick notes how wrongheaded this approach is. “Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence,” he says.

The fear people have about the idea of adherence to protocol is rigidity. They imagine mindless automatons, heads down in a checklist, incapable of looking out their windshield and coping with the real world in front of them. But what you find, when a checklist is well made, is exactly the opposite. The checklist gets the dumb stuff out of the way,

Nonetheless, even with fortune on their side, there remained every possibility that 155 lives could have been lost that day. But what rescued them was something more exceptional, difficult, crucial, and, yes, heroic than flight ability. The crew of US Airways Flight 1549 showed an ability to adhere to vital procedures when it mattered most, to

With a good checklist in hand, he was convinced he and his partners could make decisions as well as human beings are able. And as a result, he was also convinced they could reliably beat the market. I asked him whether he wasn’t fooling himself. “Maybe,” he said. But he put it in surgical terms for me. “When surgeons make sure to wash their hands

“This is basic basic basic,” he said. “Just look! You’d be amazed by how often people don’t do it.” Consider the Enron debacle, he said. “People could have figured out it was a disaster entirely from the financial statements.”

We have the means to make some of the most complex and dangerous work we do—in surgery, emergency care, ICU medicine, and beyond—more effective than we ever thought possible. But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert

He has a Day Three Checklist, for example, which he and his team review at the end of the third day of considering an investment. By that point, the checklist says, they should confirm that they have gone over the prospect’s key financial statements for the previous ten years, including checking for specific items in each statement and possible

One study in medicine, for example, examined the aftermath of nine different major treatment discoveries such as the finding that the pneumococcus vaccine protects not only children but also adults from respiratory infections, one of our most common killers. On average, the study reported, it took doctors seventeen years to adopt the new treatments

It is common to misconceive how checklists function in complex lines of work. They are not comprehensive how-to guides, whether for building a skyscraper or getting a plane out of trouble. They are quick and simple tools aimed to buttress the skills of expert professionals. And by remaining swift and usable and resolutely modest, they are saving