On my last day on the ICU rotation block, one of the patients went into an irregular heart rhythm called ventricular tachycardia. He was a 60-something year old guy with multiple medical problems and connected to a breathing machine. All of a sudden, he became unresponsive and hypotensive and had a heart rate of 150+ beats per minute. As we all rushed into the room, we systematically ran through the ACLS algorithm. We initially evaluated him, checked for pulses, started CPR, established the airway, monitored blood pressure, identified the rhythm, and gave a dose of treatment. We repeated the process until the patient was stable. It was efficient, it was effective, and most importantly it was routine. It was a checklist that was used around the world and saved many lives.
In this fantastic article, Atul Gawande describes a bomber airplane competition held by the US army in 1935. One particular plane, the Boeing Model 299, was introduced as the plane that could carry five times the amount of bombs while flying faster and farther than any other plane in the competition. There were high hopes for this plane to revolutionize the US airforce at the time. At its first flight, the Boeing 299 taxied onto the runway, took off without a problem and climbed to about three hundred feet. Then the plane stalled and crashed – killing three out of the five pilots.
- Side view of the Boeing B-17 (Model 299) after the fire was extinguished. (U.S. Air Force photo)
After further investigation, the reason for the crash was deemed “pilot error.” The new plane was so complex that not even the best pilots could master it by memory. The solution was a checklist. They created a step by step checklist on takeoff, landing, flying, and taxiing. The pilots went on to fly 1.8 million miles with the Boeing 299 without an accident. The Boeing 299 was renamed the B-17, and with the B-17, the Americans were able to have an unfair advantage in World War II by destructively bombing Nazi Germany.
Checklists seemed to work for medicine as well. In this landmark study in 2006, ICU’s in Michigan found that by implementing checklists they were able to decrease infection rates by 66%. With the checklist, the average ICU in Michigan was outperforming the rest of the nation by at least 90%. After eighteen months, nearly two million dollars and at least 1500 lives were saved in Michigan by this simple checklist. What was the checklist? Before each central line procedure, the checklist composed of just hand washing, covering the patient, cleaning the area, and removing unnecessary lines. Really simple, even more so effective.
“Good checklists, on the other hand are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything–a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps–the ones that even the highly skilled professional using them could miss. Good checklists are, above all, practical.”
― Atul Gawande, The Checklist Manifesto: How to Get Things Right
Checklists don’t need to be complicated at all. Actually, the simpler the checklist, the better. Checklists lessen our cognitive load by automating the simple tasks that need to be done. The army used the checklist to fly the B-17 safely and used their free minds to strategically bomb Nazi Germany. ICU’s in Michigan revolutionized medicine by creating a simple hand washing checklist before every complex procedure so the healthcare team can concentrate and save more lives. I helped save a life the other day by performing a routine checklist executed across the country. In each of these scenarios, simple things became automatic which allowed for more energy and creativity to be spent on the difficult things.
Here’s a simple checklist I go through everyday:
- Did I plan my day?
- Did I do the most important things first?
- Am I actively thinking about my goals?
- Am I taking regular breaks?
- Am I taking care of myself?
- Did I show gratitude to at least one person today?
- Did I review myself at the end of the day?
If no to any of the above, I usually go back and correct it or write in my personal journal on how I can correct it next time. Try this out and let me know what you think.
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doctormikesblog 
I like that checklist, especially the one about gratitude. I was only thinking myself the other day about the number of times I say “thanks” and ask “you OK?” more by habit than anything else.
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I think that you won’t have any problems since its second nature to you now!
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checklists are fantastic! i always use one when i am packing and i like to make them daily for various things
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Yeah checklists for packing are essential. I just hate it when I go on a trip and forget something like toothpaste or contact lens solution.
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Dr. Mike…I’m showing gratitude to Y-O-U today. What I like about your posts is the accompanying research. Your points are well taken. So thank you very much for giving it to us straight, which insures that we are almost certain to reap the benefits!!!
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Thank Y-O-U too! I’m glad you appreciate the research, definitely takes some time to look that stuff up!
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Does posting Post-It notes everywhere count? I encourage myself every morning and most nights I typically evaluate my behavior and how I can become better. I think I need to become more consistent with writing in my journal. Great post!
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I think at least doing something counts. As with life, there’s never one right answer, so whatever works for you!
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Love the analogies you’ve provided. I am a big list maker. It helps me stay organized when I have a lot on my plate. Now if I could only remember where I left my last list…
Kidding. It’s in my phone!
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Now that you brought it up, I wonder if adding to the checklist, “find my checklist,” would defeat the purpose of having a checklist. Oh well, it’s the thought that counts!
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Nice job weaving the checklist into the stories. In nuclear power we use checklists and procedures all the time. We say there is just a few simple thousand checklists.
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Today when I was talking to the radiologist about a patient, we were discussing about how to tackle hard problems. He put it like this: “When eating an elephant, take one bite at a time.” I never heard that saying before, but it exquisitely applies to how we use checklists for difficult topics.
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One thing to remember. Thinking Compliance. Checklists like procedures are usually good, but one can really go down the wrong path if they just blindly follow them. Every situation is different, use your system knowledge and indications to assess and act, while following the checklist as a guide.
Most checklists are made from the mistakes of the past.
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I agree, checklists are meant to be guides! We should always be actively thinking.
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Thanks for the friendly reminder about “active” thinking. I copied your simple checklist into my bullet journal.
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Thanks! I hope it helps!
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