The Checklist Manifesto: How to Get Things Right

Chapter 2 begins with a foray into the world of aviation, as Gawande discusses the creation of the B-17 bomber. The B-17 bomber’s first flight in 1935 was much anticipated. When it came time for the first flight, the plane took off and soon crashed, killing two of the five-man crew. After an investigation, the cause of the crash was revealed to be a simple pilot error. With this incident came the development of the first pilot checklist. The B-17 bomber eventually regained its reputation and was used heavily against Nazi forces during WWII. Gawande mentions that in the context of complicated situations, humans make mistakes because they are either lulled by the mundane, or simply skip steps (resulting in an all-or-none process, in which skipping a single step compromises the whole endeavor). Skipping steps often happens due to internal circumstances, such as ego, and external pressures.

Gawande mentions Peter Pronovost, a renowned surgeon at Johns Hopkins Medical Center. Pronovost studied behaviors of surgeons and nurses when they used catheter lines on patients. He discovered that many life-threatening and fatal infections were the result of care professionals skipping one of five basic, but important steps prior to inserting the lines.