The B-17 was the most sophisticated, but complicated, airplane of its time. Boeing lost a government contract to Douglas due to its complexity. To make it flyable, they created a pilot’s checklist. Pilots had never needed them before, but they helped to fly increasingly complex machines.

In every hospital, four vital signs are checked constantly: temperature, pulse, blood pressure, and respiratory rate. This is a kind of patient checklist that helps to catch problems early. Checklists guard against two human foibles: faulty memory and skipping protocol. Nurses first implemented this checklist in hospitals in the 1960s to help manage their duties.

In 2001, Peter Pronovost tried a doctor’s checklist to prevent central line infections at Johns Hopkins. After implementing the checklist, which included granting nurses authority over procedure, the rate of line-infections plummeted. They experimented with other checklists and found that, at the very least, they helped to improve consistency in patient care.

Adoption of the checklists was low. Pride and doubt about evidence limited interest. Then, Pronovost tried the checklists at Sinai-Grace in Detroit. Sinai went from having one of the worst line infection rates to one of the best. One important part of this was the buy-in from management. Management helped to make sure that the tools were available, but did not force the checklist down throats.

Gawande goes back to the story of the drowned girl in Klagenfurt. She was saved due to careful review of procedure with all stakeholders and a checklist.