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REFRACTIONS - By Henry Petroski

Operating Instructions

A surgeon finds a key to medical safety —

and newfound respect for engineers.

Photo: HENRY PETROSKI - Strikingly detailed animation sequences show cranes in action, concrete being placed for foundations, and steel hoisted into place to build towers.On the strong recommendation of a trusted colleague, I recently read a book that proved to be fascinating on several levels. The book is The Checklist Manifesto: How to Get Things Right by the surgeon Atul Gawande, and it presents a convincing argument for the efficacy of operating-room teams going down a checklist before beginning surgery.

After noting that there are three times as many deaths attributed to complications from surgery as there are from highway accidents each year, Gawande chronicles his quest for ways to make the operating room safer. Among the places he looks to for ideas are the construction site and the airplane cockpit, both considered domains in which engineering plays a central role.

Building failures in the United States are extremely rare, Gawande notes, and he cites a 2003 Ohio State University study that found there have been only about 20 partial or full collapses per year in a population of over 100 million existing buildings. To find out how the industry achieves such a high success rate, he interviewed the structural engineer responsible for the design of a new wing being built for a Boston hospital.

Upon first meeting, the surgeon found the engineer to be other than what he had expected. Indeed, Gawande found he had “a cheery, take-your-time, how-about-some-coffee manner” rather than, we must assume, the gloomy, rushed, let’s-get-right-down-to-work style for which engineers might be known, at least among surgeons. The doctor liked the engineer’s desk-side manner. But this was really a business call, for the doctor wanted to know how structural engineers achieved such high rates of success in erecting skyscrapers and other buildings.

Talking later with the “project executive” for the new hospital wing, Gawande learned that the secret to construction success lay in the critical-path method of scheduling, which the doctor saw as a checklist. He saw that the amount of knowledge and degree of complexity the project executive had to manage “were as monstrous as anything [he] had encountered in medicine.” This gave him a newfound respect for engineers, from whose practices he thought surgeons could learn.

Gawande was also impressed by the system by which problems were resolved on the building site. In addition to the construction schedule, there was a “submittal schedule,” which effectively listed communication tasks to be completed. These tasks were necessary so that the many different groups involved in the project would be on the same page regarding when the project was ready to move to a new phase. The surgeon saw this as another form of checklist.

He also looked to the commercial airline industry, whose safety record is well known. He visited a person at Boeing responsible for developing checklists to cover everything from normal engine startup to such in-flight emergencies as a cargo door latch failure or sudden engine shutdown. The sequence of tasks to be performed under such circumstances also was deemed a checklist.

Convinced that checklists would bring improved safety to the operating room, Gawande and his team developed and tested them. After a six-month trial period, they found that the rate of major complications for surgery patients fell by 36 percent, and deaths declined by 47 percent. The lessons learned from engineering good practice had produced medical results greater than expected.

Gawande has become an ardent proponent of checklists, and his Checklist Manifesto is an eloquent and persuasive call for greater use of them in all areas of hospital treatment and care. His book is equally valuable for its recognition that engineering has a lot to offer other professions.


Henry Petroski is the Aleksandar S. Vesic Professor of Civil Engineering and a professor of history at Duke University. His latest books are An Engineer’s Alphabet: Gleanings from the Softer Side of a Profession (2011) and To Forgive Design: Understanding Failure (2012).


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