The Power of the Checklist

In 2001, a critical care specialist named Peter Pronovost created a simple checklist for inserting central line catheters. Five steps. Wash hands. Clean the patient's skin. Use sterile drapes. Wear a mask, hat, and gown. Put a sterile dressing over the insertion site.

Doctors already knew all five steps. They'd learned them in medical school. They'd done the procedure hundreds of times.

But when Pronovost tracked compliance, he found that doctors skipped at least one step in more than a third of patients. When he implemented the checklist at Johns Hopkins, the ten-day line infection rate dropped from 11% to zero. Over 15 months, the checklist prevented 43 infections, 8 deaths, and saved $2 million.

A piece of paper with five items on it saved eight lives.

The problem with expertise

Atul Gawande wrote about this in The Checklist Manifesto. His central insight: the problem in complex work isn't ignorance. It's ineptitude. We have the knowledge. We fail to apply it consistently.

Expertise creates confidence. Confidence creates shortcuts. Shortcuts create errors. The more experienced you are, the more likely you are to skip steps you consider routine.

This isn't a character flaw. It's how human attention works. We can't maintain perfect focus on routine tasks. Our minds wander. We get interrupted. We assume we'll remember. We don't.

Checklists compensate for these limitations. They don't replace expertise. They ensure expertise gets applied consistently.

Why checklists work

Checklists work because they externalize memory. Instead of relying on recall, you rely on recognition. The checklist prompts you. You respond.

This sounds trivial. It isn't. Recognition is far more reliable than recall. You might forget to clean the patient's skin. You won't forget if a checklist is asking you whether you cleaned the patient's skin.

Checklists also work because they establish a minimum standard. When a step is on the checklist, skipping it becomes a conscious decision. You have to actively choose not to do it. Without a checklist, skipping happens by default. The omission is invisible.

Finally, checklists work because they distribute responsibility. In a team context, anyone can call out a missed step. The checklist gives them permission. It makes the standard explicit.

The resistance to checklists

Despite the evidence, many professionals resist checklists. Especially experts.

The objection is usually some form of "I don't need a checklist. I know what I'm doing." This misses the point. The checklist isn't about knowing. It's about doing. Consistently. Under pressure. When you're tired. When you're distracted. When you've done it a thousand times and your brain is on autopilot.

Another objection: "Checklists are for simple tasks. My work is too complex." Gawande addresses this directly. The most complex fields use checklists the most. Aviation. Surgery. Construction. Complexity is exactly why you need them.

The real resistance is often ego. Checklists feel like an admission that you might make mistakes. That you're not as reliable as you think. This is uncomfortable. It's also true.

Types of checklists

Not all checklists are the same. Gawande identifies two types:

DO-CONFIRM checklists. You do the work from memory, then pause and run through the checklist to confirm you didn't miss anything. This works for experienced teams doing familiar tasks.

READ-DO checklists. You read each item, then do it, then move to the next. This works for less experienced teams or for tasks where the sequence matters.

The choice depends on context. But both types share a key feature: they're used at specific pause points. You don't check the list constantly. You check it at defined moments.

What makes a good checklist

Bad checklists are long, vague, and impractical. People ignore them. Good checklists are short, precise, and tested in real conditions.

Some principles:

Keep it short. Gawande suggests 5 to 9 items. More than that, and people start skipping. A checklist should fit on one page. Ideally, it should fit on one side of an index card.

Focus on killer items. Not every step needs to be on the checklist. Include the steps that are most critical and most often missed. The checklist catches the errors that matter most.

Use simple language. No jargon. No ambiguity. Each item should be a clear action. "Confirm patient identity" not "Ensure proper identification protocols."

Test and revise. Your first checklist won't be perfect. Use it. Notice what doesn't work. Update it. The best checklists evolve through practice.

Make it easy to use. If the checklist is buried in a drawer, it won't get used. If it's laminated and sitting at the workstation, it will.

Checklists for leadership teams

The medical and aviation examples are dramatic. But the principle applies everywhere. Including leadership.

Think about the recurring processes in your organization:

Launching a new project. Onboarding a new hire. Running a board meeting. Closing a quarter. Conducting a post-mortem.

Each of these has steps that matter. Steps that get skipped when you're busy. Steps where a miss creates problems downstream.

A checklist for project launches might include: Define success metrics. Identify the owner. Set the timeline. Communicate to stakeholders. Schedule the first check-in.

You know all these steps. Your team knows them too. But without a checklist, someone forgets the success metrics. Someone assumes the owner is obvious. The project starts fuzzy and stays fuzzy.

The commitment checklist

One powerful application: a checklist for commitments.

Every time someone commits to doing something, certain information matters. Who owns it. What specifically they're delivering. When it's due. How it connects to strategic priorities. Who needs to know when it's done.

Without a checklist, some of this gets captured. Some doesn't. It depends on who's in the meeting. How good the note-taker is. Whether someone remembers to follow up.

With a checklist, every commitment gets the same treatment. The information is always captured. The ambiguity is always resolved. The follow-through is always clear.

The meeting end checklist

Another application: ending meetings well.

Most meetings end poorly. Time runs out. People scatter. The conversation felt productive, but nothing concrete emerged.

A simple end-of-meeting checklist:

What decisions did we make? What commitments did we make? Who owns each commitment? When are they due? Who needs to be informed?

Takes two minutes. Transforms the meeting from talk to action.

The weekly review checklist

A third application: the weekly review.

David Allen recommends weekly reviews as the cornerstone of personal productivity. The same applies to teams. A weekly pause to check: What's on track? What's at risk? What got missed? What's the focus for next week?

Without a checklist, weekly reviews wander. They skip important areas. They end without clear takeaways.

With a checklist, the review hits every important point. Every priority gets attention. Every person gets accountability.

The humility of the checklist

Using a checklist is an act of humility. It says: I know I'm not perfect. I know I'll forget things. I know that under pressure, I'll skip steps. So I'm building a system that catches my errors before they cause harm.

This humility is a strength, not a weakness. The best performers in every field use checklists. Not because they're less skilled. Because they're honest about human limitations.

Your team makes commitments every day. Some get followed through. Some get forgotten. A checklist won't fix everything. But it will catch the errors that expertise misses.

Start with one process. Build a short checklist. Use it for a month. See what happens.