The Checklist Manifesto (25 page)

174
“ ‘That was so long ago’ ”: “Sully’s Tale,”
Air & Space
, Feb. 18, 2009.

178
“Once that happened”: C. Sullenberger and J. Zaslow,
Highest Duty: My Search for What Really Matters
(New York: William Morrow, 2009).

179
“Skiles managed to complete”: Testimony of Captain Terry Lutz, Experimental Test pilot, Engineering Flight Operations, Airbus,
National Transportation Safety Board, “Public Hearing in the Matter of the Landing of US Air Flight 1549 in the Hudson River, Weehawken, New Jersey, January 15, 2009,” June 10, 2009.

180
“ ‘Flaps out?’ ”: D. P. Brazy, “Group Chairman’s Factual Report of Investigation: Cockpit Voice Recorder DCA09MA026,” National Transportation Safety Board, April 22, 2009.

180
“For, as journalist and pilot”: W. Langewiesche, “Anatomy of a Miracle,”
Vanity Fair
, June 2009.

181
“After the plane landed”: Testimony of Captain Chesley Sullenberger, A320 Captain, US Airways, National Transportation Safety Board, Public Hearing, June 9, 2009.

Three kinds of people were pivotal to this book: the ones behind the writing, the ones behind the ideas, and the ones who made both possible. As the book involved background research in several fields beyond my expertise, the number of people I am indebted to is especially large. But this book could never have been completed without all of them.

First are those who helped me take my loose observations about failure and checklists and bring them together in book form. My agent, Tina Bennett, saw the possibilities right away and championed the book from the moment I first told her about my burgeoning fascination with checklists. My editor at the
New Yorker
, the indispensable Henry Finder, showed me how to give my initial draft more structure and my thinking more coherence.
Laura Schoenherr, my brilliant and indefatigable research assistant, found almost every source here, checked my facts, provided suggestions, and kept me honest. Roslyn Schloss provided meticulous copyediting and a vital final review. At Metropolitan Books, Riva Hocherman went through the text with inspired intelligence and gave crucial advice at every stage of the book’s development. Most of all, I leaned on Sara Bershtel, Metropolitan’s publisher, with whom I’ve worked for nearly a decade now. Smart, tough, and tireless, she combed through multiple drafts, got me to sharpen every section, and saved me from numerous errors of tone and thinking, all the while shepherding the book through production with almost alarming efficiency.

As for the underlying ideas and the stories and experience fleshing them out, I have many, many to thank. Donald Berwick taught me the science of systems improvement and opened my eyes to the possibilities of checklists in medicine. Peter Pronovost provided a crucial source of ideas with his seminal work in ICUs. Lucian Leape, David Bates, and Berwick were the ones to suggest my name to the World Health Organization. Sir Liam Donaldson, the chair of WHO Patient Safety, who established the organization’s global campaign to reduce deaths in surgery, was kind enough to bring me aboard to lead it and then showed me what leadership in public health really meant. Pauline Philip, the executive director of WHO Patient Safety, didn’t take no for an answer from me and proved extraordinary in both her dedication and her effectiveness in carrying out work that has now extended across dozens of countries.

At WHO, Margaret Chan, the director general, as well as Ian Smith, her adviser, David Heymann, deputy director general, and
Tim Evans, assistant director general, have all been stalwart supporters. I am also particularly grateful to Gerald Dziekan, whom I have worked with almost daily for the past three years, and also Vivienne Allan, Hilary Coates, Armorel Duncan, Helen Hughes, Sooyeon Hwang, Angela Lashoher, Claire Lemer, Agnes Leotsakos, Pat Martin, Douglas Noble, Kristine Stave, Fiona Stewart-Mills, and Julie Storr.

At Boeing, Daniel Boorman emerged as an essential partner in work that has now extended to designing, testing, and implementing clinical checklists for safe childbirth, control of diarrheal infections, operating room crises, management of patients with H1N1 influenza, and other areas. Jamie and Christopher Cooper-Hohn, Roman Emmanuel, Mala Gaonkar and Oliver Haarmann, David Greenspan, and Yen and Eeling Liow were early and vital backers.

At the Harvard School of Public Health, the trio of William Berry, Tom Weiser, and Alex Haynes have been the steel columns of the surgery checklist work. The WHO Safe Surgery program I describe in this book also depended on Abdel-Hadi Breizat, Lord Ara Darzi, E. Patchen Dellinger, Teodoro Herbosa, Sidhir Joseph, Pascience Kibatala, Marie Lapitan, Alan Merry, Krishna Moorthy, Richard Reznick, and Bryce Taylor, the principal investigators at our eight study sites around the world; Bruce Barraclough, Martin Makary, Didier Pittet, and Iskander Sayek, the leaders of our scientific advisory group, as well as the many participants in the WHO Safe Surgery Saves Lives study group; Martin Fletcher and Lord Naren Patel at the National Patient Safety Agency in the U.K.; Alex Arriaga, Angela Bader, Kelly Bernier, Bridget Craig, Priya Desai, Rachel Dyer, Lizzie Edmondson,
Luke Funk, Stuart Lipsitz, Scott Regenbogen, and my colleagues at the Brigham and Women’s Center for Surgery and Public Health; and the MacArthur Foundation.

I am deeply indebted to the many experts named throughout the book whose generosity and forbearance helped me explore their fields. Unnamed here are Jonathan Katz, who opened the door to the world of skyscraper building; Dutch Leonard and Arnold Howitt, who explained Hurricane Katrina to me; Nuno Alvez and Andrew Hebert, Rialto’s sous chefs, who let me invade their kitchen; Eugene Hill, who sent me the work of Geoff Smart; and Marcus Semel, the research fellow in my group who analyzed the data from Harvard Vanguard Medical Associates showing the complexity of clinical work in medicine and the national data showing the frequency of death in surgery. In addition, Katy Thompson helped me with the research and fact-checking behind my
New Yorker
article “The Checklist,” which this book grew out of.

Lastly, we come to those without whom my life in writing and research and surgery would be impossible. Elizabeth Morse, my administrative director, has proved irreplaceable, lending a level head, around-the-clock support, and continually wise counsel. Michael Zinner, the chairman of my surgery department at Brigham and Women’s Hospital, and Arnie Epstein, the chairman of my health policy and management department at the Harvard School of Public Health, have backed me in this project as they have for many others over the last decade and more. David Remnick, the editor of the
New Yorker
, has been nothing but kind and loyal, keeping me on staff through this entire period. I could not be more fortunate to have such extraordinary people behind me.

Most important, however, are two final groups. There are my
patients, both those who have let me tell their stories here and those who have simply trusted me to try to help with their care. I have learned more from them than from anyone else. And then there is my family. My wife, Kathleen, and children, Hunter, Hattie, and Walker, tend to suffer the brunt of my mutating commitments and enthusiasms. But they have always found ways to make room for my work, to share in it, and to remind me that it is not everything. My thanks to them are boundless.

Atul Gawande is the author of
Better
and
Complications
. A MacArthur Fellow, a general and endocrine surgeon at the Brigham and Women’s Hospital in Boston, a staff writer for
The New Yorker
, and an associate professor at Harvard Medical School and the Harvard School of Public Health, he also leads the World Health Organization’s Safe Surgery Saves Lives program. He lives with his wife and three children in Newton, Massachusetts.