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Post-surgical deaths in Scotland drop by a third, attributed to a checklist (bbc.co.uk)
1036 points by fanf2 on April 17, 2019 | hide | past | favorite | 366 comments

My former roommate is a pilot. When I first met him, I noticed that he uses checklists for just about everything, even the most basic everyday tasks.

After some time, I decided to apply that same mentality to my own life. Both in private and work situations.

I get it now. Checklists reduce cognitive load tremendously well, even for basic tasks. As an example: I have a checklist for when I need to travel, it contains stuff like what to pack, asking someone to feed my cat, check windows are closed, dishwasher empty, heating turned down, etc. Before the checklist, I would always be worried I forgot something, now I can relax.

Also, checklists are a great way to improve processes. Basically a way to debug your life. For instance: I once forgot to empty the trash bin before a long trip, I added that to my checklist and haven't had a smelly surprise ever since ;)

Good checklist design is not trivial, however. I use checklists professionally, and the list rapidly accumulates cruft for problems that have been solved by design. E.g., suppose one time someone forgot to sign your software release. "Verify release has been signed" is added to the checklist. However a bright soul also integrates signing into the release build. Thus the problem is essentially solved once and for all, but the item will remain on the checklist in perpetuity, which adds overhead & decreases confidence in the checklist process.

I think they make sense for infrequently exercised routines of moderate complexity that are 100% execution. A complex but limited scope machine like a plane is really an ideal example. I guess preparing for a vacation could be another, although I get caught up because packing is totally different every time. I suppose I checklist myself when I rappel or go skiing ("Skins, skis, boots, ... working up the body")

> but the item will remain on the checklist in perpetuity,

Why do you say this?

Everytime you see a system flaw because of a missed step, you add to checklist. Everytime you have a process flaw because of a uselss step, you remove from the checklist. There's no problem here, checklist maintenance can be a step in the checklist.

> ("Skins, skis, boots, .

"Spectacles, testicles, wallet, and watch!"

A release checklist (for us) is inherently very risk-averse, as its raison d'être is to prevent a very expensive & dire catastrophe, and every item on the list is (metaphorically) "written in blood" [0]. As a result it's politically intractable to remove anything.

[0]: https://medium.com/war-is-boring/u-s-navy-supercarriers-domi...

I would say that a system too entrenched to consider removing anything, is fundamentally at risk of not being able to correctly analyze the system when adding anything to the checklist, and is itself at an increased risk to fail.

The problem is it is easy to look an item and say "we no longer need this, remove it". It is much harder to be sure you are fixed all possible ways the problem could have happened. Maybe the system auto-signs the release - but does it in all cases? Is there a rare special case where the automatic process doesn't happen? Do you really know what tricks they have to pull in that branch office in India?

That's why the same consideration to adding an item needs to be put into removing an item, need to be put into reviewing if the checklist is relevant still at all.

Broken down a different way, you need two systems: an automatic system so you're not reconsidering decisions that have good outcome (a checklist), and a considerate system that decides what goes into or out of the automatic system.

If the considerate system is broken or just frozen, then you have a problem. How long it will take to manifest is a different question.

I think there's an asymmetry that you're not quite capturing here: when you add an item to the checklist, you have a specific concrete failure at hand (the process just failed, you had everyone on hand to do your root cause analysis, and you know exactly why). Later when you want to remove it, you (a) lose context because time has passed and memories are fallible and/or a different person is dealing with it, and (b) you have to have some reasonable assurance that you've covered other ways the same failure can occur. No amount of process can completely eliminate this asymmetry so at some point you're forced to make a tradeoff based on how risk averse you want to be.

The problem is not lost context. The problem is that adding an item to a checklist protects you from a category of outcomes. If you have a checklist item to make sure a release is signed, you will never push an unsigned release.

Removing an item from a checklist is done in response to a change in inputs. Sure, you may have automated release signing - but unless you are 100% confident that you are aware, and have mitigated 100% of the ways in which this can fail, you cannot, and should not remove the 'check that the release is signed' step.

Lost context has nothing to do with this. Unless you are an omniscient god, you probably cannot reason, with 100% certainty, that you have mitigated every possible input that produced a bad output.

So, check your outputs.

So it could be an automated test to check if the release is signed as well instead of a checklist item.

Having long checklists for comparatively simple tasks really hurts productivity, plus they're often used as an excuse to put automation in place, because 'the process is already defined' and 'people are already used to it'.

When designing a process, it is of utmost importance to keep checklist lengths minimal.

I can definitely concede there can be some asymmetry, but I think it's system dependent.

As the Boeing 737 Max 8 shows, adding new items (in this case a new design element) is also fraught with risks. You have to get the root analysis correct when adding or removing elements. Adding has risks of unknown (not accounted for) like removing has risks of unknown (accounting forgotten).

In the end, I guess I still believe the best strength is in good analysis at the consideration stage.

Adding a design element is completely different from adding an item to a checklist.

The asymmetry with checklists is that it's completely risk-free to add a new check, but it's risky to remove one. For example, someone might say "we're not totally sure that our system won't fail when we do X, so let's check that in QA, or at runtime, or at takeoff, or whatever." Now that the check is there, it protects you from failures when you do X. And now you're in a situation where you can't safely remove that from the checklist unless you can prove that your system won't fail when you do X. Adding requires only a suspicion, removing requires rigorous proof.

The case you describe with the 737 Max isn't the same at all. There's an actual risk when adding a new component to the system, but no risk when adding additional verification. That's not to say that there aren't other costs, but it can't directly make your system less reliable.

Just one example: If I add a step of, If patient enters with heart attack symptom X, was patient injected with 100cc of <drug>?

It's not a risk free check at all. It will likely increase the rate at which the drug is administered, with all types of plusses and minuses associated with adding a component to a system.

I think the case of 737 max is they game the checklist approach - use the guy who should be checked to be the guy to check it. Hence the argument to remove an item is so dangerous. (But then it is also may be bad blood. Life is more complex than a checklist. )

But the point of Chesterton's fence is not that you should never knock down a fence :P

But what it does do is tell us that the difficulty of removing a fence is irrelevant to its utility. :)

I feel like it is the reason why disruption works so well: After an organisation exists for a while, 100s of fences are clogging up the streets. Some of them useful, some of them used to be useful, some of them never thought out well to begin with.

So disruption is taking a bulldozer, and driving right over them. The clearly usefull fences get erected quickly. The forgotten usefull ones are rediscovered after a while, maybe causing some minor damage in the process. But the grand majority turned out to be useless, and is now gone for good.

Of course, if there is a pack of nuclear civilization killing wolves out there, they better stay fenced off or else. The trick is identifying them. There might be a role for a regulator in there.

So the issue isn’t with checklists, it’s with policy.

policy is just a way to record a decision-making process. Yet he issue is that getting the right information to be reasonably sure it’s safe to remove a checklist item is hard and made harder the longer ago the item was added

Agreed. But items can move to other checklists. In this case the list item should become a unit test for the signing code since a unit test is essentially a check list for automated systems.

Where do you work, so that I know to avoid it? Documentation needs updating as things change.

Long time ago when I was living with my parents, our family checklist was "Gas, light, water, cellphone, cat".

Check that the gas stove is off (important). Lights off. No running water (after a few, um, incidents). You didn't leave your phone, did you, and make sure the cat didn't run out (he'd always try).

I always wondered why "lights" were on the list, since nobody gave a damn about electricity bills.

Guess for the same reason that "testicles" are in the parent comment's list :)

Except "spectacles, testicles, wallet, and watch" is the Catholic sign of the cross (face, lower torso, left chest, right chest). Nothing to do with checklists.

I meant that "light" was on the list because it made the phrase roll off the tongue easier.

I've found cellphones don't need to be on the list but the charging cords do!

Leaving the lights on with the curtains drawn - and possibly the radio playing - is a hack to discourage break-ins. Someone seems to be home, but burglars can't actually look inside to check.

Too many people use that trick now. Even the 'put a light in an automatic timer' trick is common.

Instead just put a sign up that says "Any unauthorized testicles entering the building will be donated to a good cause".

Electric company propaganda!

I think a more modern version of that last checklist would include keys and phone.

> I think they make sense for infrequently exercised routines of moderate complexity that are 100% execution

Yes. There have been several formal studies of this effect, e.g. [0]. Checklists offset skill fade, which is in effect the 'forgetting curve'. Some skills (the classic riding a bike) last for ages, others (a good example being field fault diagnosis) are lost very quickly even with good initial training.

Incidentally, I once made a good camping packing checklist by making an inventory of the contents of my car as I unpacked it at the end of a holiday and the things I'd forgotten were still fresh in my mind.

[0] https://www.gmc-uk.org/-/media/about/skills-fade-literature-...

Sounds like you need to add "Periodically review & maintain checklist" to your checklist.

And don't forget to make a Checklist review checklist so you don't mess up your checklist review.

But add a counter to detect recursion and break..

> I suppose I checklist myself when I rappel or go skiing ("Skins, skis, boots, ... working up the body")

This is a perfect example. I have a snowboarding checklist and it's reduced the cognitive load of packing tremendously.

Things to do the night before, stuff to wear for the drive, stuff to pack, what to include if I'm expecting extra cold weather, and a final checklist for things to do in the morning (e.g. get lunch out of the fridge).

For travel I have a checklist of things that I always need to take (toiletries, spare phone battery, Nalgene, pajamas) and then the stuff that varies is all I have to think about. Almost every time I travel there's something on my list of "stuff that always gets packed" which I would have forgotten.

I even take it a step further and I have a dedicated storage bin for all of my ski gear. When I get home, I religiously wash everything, then put it all 100% back in the bin. Next time I go skiing, I just grab everything out of the bin. Rinse and repeat.

Is religious washing like baptising?

Hell, I do the same thing when traveling. I 'get dressed' in my head to check that I'm entirely clothed. If I weren't as good at visualizing things I'd probably just write it down.

I never forget socks but I've had to buy a few toothbrushes and deodorant...

I always have to remind my wife that there are stores along the way - she is the pack the kitchen sink type.

Another situation in which it helps I think : cooking. At least for me a checklist (written or mental) helps keeping the kitchen clean a makes better meal. For a few years now I've started to plan my cooking like I plan more abstract algorithms.

Recipes are checklists too.

Also: Mise en place

I trust that someone in the near future will mess with the release build process and the signage will be dropped. Or there might be cases when the signature is suddenly invalid for reasons you cannot forsee yet. Keep the item on the list, especially if it checks the outcome of a longer process.

Maybe an item on the checklist to refactor the checklist (as needed)?

Or maybe a checklist for refactoring all the checklists?

/this could get out of hand...

You don't need that in the checklist. But what you do need is a periodic review of checklists and other procedure and process documents.

Suppose you have training material for new hires ("How we use git 101"). Do you hand them the same document from 10 years ago? Does it have accurate setup instructions (now you use Bitbucket and not Gitlab or vice versa, and it presents internally on a different domain).

All of these kinds of documents should be reviewed with some frequency (and ideally you should have a way to submit changes outside of the explicit review times, the explicit reviews are to catch things that weren't found earlier; wikis can help here). If you don't, then you do end up with the problem being discussed. You'll have a lot of checklists or procedures being done "because it says so" and not because they're needed.

At some point you have to run through the process with enough disengaged brain cells that you can think about what you're doing while doing it. With processes that only get used in emergencies, this doesn't happen often enough.

I suspect that's part of the secret behind Netflix Chaos Monkey. Every single process gets run multiple times a month, and it's normalized enough that it's not a constant panic mode thing.

I would argue that you want an automated check for "verify release has been signed" then if it fails you are alerted. This is better than manually checking it every time or assuming it will always be signed. A trust but verify approach. Then one day you may find that a trusted cert has expired and signing is broken or a key is not available b/c it got accidentally deleted etc... Lots of things can go and will go wrong.

I confess to not usually using a checklist when I travel because most times are a bit different. What I do though--I travel a lot--is I have a couple containers of "travel stuff" down in my kitchen including some pre-made kits that I just throw in my bag. I pick out what I need, add clothes as needed, and that works pretty well.

> I confess to not usually using a checklist when I travel because most times are a bit different.

Don't you find that most trips have a ton of stuff in common though? Pajamas, contact case/solution, loofah, spare phone battery, ear plugs, phone charger & battery charger, reusable water bottle, etc. always go with me on every trip.

IMO the stuff that always goes is the stuff that I tend to forget, exactly because there's nothing unique about this trip that would make me remember it. If I'm going to the beach I know I need my swimsuit and beach shirts because I can walk through my activities and think about what I need for each one. But I'm likely to forget pajamas because I'm not thinking about "go to bed every night" as an activity to plan for.

A lot of the things you describe (or my versions thereof) are in one of the kits I always bring and the others are elsewhere in the container I rifle through when packing. Sure, I could have a checklist (and probably should) but forgetting the basic stuff isn't something I have a regular problem with. I do travel every few weeks so I have the routine pretty well down.

Apart from the pajamas, you could easily just buy extras of those things and keep them together for travelling. It's so much easier just to grab a set and check afterwards what needs to be replaced or refilled.

This is why I use OmniFocus for my travel checklist: nested lists. If I’m not going on a ‘work trip’ I can just tick that whole sub-list off with one tap.

Checklists FTW. Nobody above me has mentioned Atul Gawande’s book ‘The Checklist Manifesto’ so, just on the off-chance you’re not aware of it, there you go. I loved it. (Gawande is the doctor who implemented the checklist in this article.)

I've been using packing crates, which helps.

I have a packing crate for socks, one for underwear, one for causalwear and pants.

Then I just need to think how many nights I'll be gone to pick how much goes into each.

(Also reduces space in my carry on so I have room for conference schwag on the return leg)

The bottom line, if you travel a lot, is to essentially leave your bags packed for a typical trip. I might need to top some medications off, pack the right amount of socks and underwear, decide on the clothes for a particular trip given weather/activities, electronics, etc. It sounds like a lot of stuff but I can basically grab what I need for a typical 3-7 day trip in less than 30 minutes.

The other thing is just bring less stuff. A lot of people are amazed by how little I carry and I don't consider myself extreme. Consider what you really need as opposed to want.

I started using a hanging basket in my bathroom I can just throw in, but it's not feasible to leave my bags backed if for no other reason than the clothes would wrinkle.

(Then again maybe I'm not travelling enough for your advice to apply...)

I agree on the bringing less stuff front. I've slowly pared down a lot of what I bring, and just stop in a drugstore to pick up if I forgot some minor thing.

A good reusable checklist system can help with this. I've been using an app called SplashShopper since the Palm Pilot days that lets me choose what I need for any particular trip from a list of common items. This lets the list adapt to the particular needs of each trip. It's the only app I've ever found that hits this sweet spot of reusability. Unfortunately the company that makes it does a poor job of updating it for iOS, so I keep an ancient iPad around just so I can keep using it.

> Good checklist design is not trivial, however.

I understand you're saying, but this statement exemplifies so well something I think I have gotten worse at since becoming a software engineer.

In my previous life, if I tried to apply checklists to my life, I would have taken a naive approach, applied my best effort, and that would be the end of it.

Now I would be much more likely to consider edge cases and counter-examples, compare my checklists to the "optimal checklist", and as a result I might fall into a checklist-design rabbit hole, or else constantly question the efficacy of my checklists in knowledge of the true complexity of the problem.

I don't think it's always beneficial to think in those terms.

I feel like some people have vastly different sensitivities to doing pointless things. There are some people who would see items like that on the checklist, and go, okay, it's a minute to check that, no big deal, I'll do it and get on with my life. There are people who look at it and are almost offended that their time is being wasted by process. I don't really know what to DO about this, but I do find it's one thing that makes collaborating difficult when a group has members with vastly different tendencies in this regard.

>"Verify release has been signed" is added to the checklist. However a bright soul also integrates signing into the release build.

If that bright soul also added a 'verify the signature' step to the build process, and the ability for the build system to know that signing failed, you've automated the entire thing and now your checklist is documentation for the build process.

Curating a list isn't about building it as much as it is about maintaining it.

Then remove it from the check list? They're not immutable.

Create a checklist to review your other checklists on a schedule?

This is described in the book called "the checklist manifesto". Very good book by the way.


Agreed, the book was very well written and the audiobook had a great narrator.

Because of that book, I'm not surprised that the checklist reduced deaths, but its a bit shocking that its by a third. Then again, the base rate was very low to begin with, showing that surgery teams were already doing a seemingly good job:

"The death rate fell to 0.46 per 100 procedures between 2000 and 2014, analysis of 6.8m operations showed."

Still, over 6.8 million operations, is that 15,000 survivals? Wow.

One big difference, I've always suspected, is that a plane crash is very visible and affects hundreds of people at once.

Somebody sick dying in hospital, on the other hand, is just something that happens, and draws very little attention - even though way more people are affected than in plane crashes.

So, the clustering and visibility of plane crashes leads to excellent check list discipline and other best practices in aviation, by and large (CRM, Crew Resource Management, is another thing Atul Gawande brings up in The Checklist Manifesto, and also eminently transferable to surgery), while I suspect that in surgery it is easier to drift away from best practices again without anyone noticing.

That's why these large studies and the educational efforts of Dr Gawande and others are so important.

edit: typo

Yes, that’s probably the reason because mistakes in health care is an absolutely massive killer. In the US alone it’s responsible for about as many deaths as if two jumbo jets collidee with each other every day. The number of people dying from the simple fact that health care practitioners are humans and humans get tired, drunk, angry, careless or just plain stupid for random reasons is mind boggling.

If we saw a midair collision of jumbo jets every day however the public would never accept it.


Read this: https://www.newyorker.com/magazine/2007/12/10/the-checklist

Same author as the book, but earlier. Contains all the meat, but none of the repetitions and the tenuous analogies.

Gawande had enough for a long-form article, but not for a book, and IMO it shows.

The book isn't bad. It's just that the essay is better.

There seems to be minimum book size that forces inflation in a whole genre of self-help books that genuinely have good advice. I've read books where all of the advice I need is in the end-of-chapter checklists.

On one hand, it's good to err on the side of too-long a book, as it's easier to skip fluff than to seek out more details, illustrations, and alternative phrasings that aren't in the book. On the other hand, it's annoying to have the extra weight in volume in one's book collection.

I was lamenting this exact thing to a friend the other day. Books are just too long for most self-help advice and it ends up being 80% filler.

The worst is when the first three chapters are about how rich/smart/successful you'll become by reading this book! (Except for the first three chapters, of course, because those are just advertisements for the book you already acquired.)

To solve this I subscribe to blinkist where they have summarized every self help book into a 15 minute read. It costs money but the summarization of content is worth it. I've read hundreds of self help essays (books) with blinkist.

Does not the book also give more insight about how applying the principles to someone everyday life ?

I also didn't think this. I've read the book but not the article, and while the conclusion seems fine, a lot of the material in the book is stretched.

The one that bothered me the most was the inclusion of the India soap program as support for checklists -- those are entirely different models.

The soap model involved researchers handing out free soap, and teaching people that they should wash with the soap in any of a set of specific circumstances:

    - once a day (full body)
    - before preparing food (hands)
    - before eating (hands)
    - before distributing food to anyone (hands)
    - after defecating (hands)
    - after wiping an infant (hands)
This made a big dent in the prevalence of disease in experimental neighborhoods. Great! This was a good idea. But it's not an example of a checklist. The concept here is that, every time you do anything at all, you see whether it's one of those five hands-washing circumstances, and if it is, then you wash your hands. This is the opposite of a checklist, where you perform a series of verifications whenever you take a specific particular action, not whenever you take any action at all.

(Obviously, people can't handle the mental load of "before doing _anything_, check to see..." and instead would have added "wash your hands" to the appropriate five behavioral sequences. That reduces the mental load from (1) a constant mental drain on any activity of any kind to (2) learning five things. But if you make that switch, you stop having any relationship to the checklist concept at all.)

Why do you think so? I don't.

The article in The New Yorker is superb, you should really take a look. What could be missing there?

The medical community uses checklists. They've been using checklists for a while. A number of studies found that they only help for a few months, while they're new.

That said, "the medical community" is not a homogeneous monolith, and you can absolutely find regional variation in what checklists are used for, how detailed they are, how closely they're followed, how people are accountable for keeping to them, etc.

"The Checklist Manifesto" chose to overlook the studies about how transient the benefit of checklists is.

> A number of studies found that they only help for a few months, while they're new.

This 2014 review looked at 34 studies that looked at the effectiveness of safety checklists:

> The main findings were improved communication, reduced adverse events, better adherence to standard operating procedures, and reduced morbidity and mortality. None of the included studies reported decreased patient safety or quality after introducing safety checklists.

> Safety checklists appear to be effective tools for improving patient safety in various clinical settings by strengthening compliance with guidelines, improving human factors, reducing the incidence of adverse events, and decreasing mortality and morbidity. None of the included studies reported negative effects on safety.

So I'm going to ask for a citation on that claim.


Could like point out the studies you mentioned?

The studies concerning long-term impact of surgical checklists I found all claim an improvement.

> Sustained use of the checklist was observed with continued improvements in process measures and reductions in 30-day surgical complications almost 2 years after a structured implementation effort that demonstrated marked, short-term reductions in harm. The sustained effect occurred despite the absence of continued oversight by the research team, indicating the important role that local leadership and local champions play in the success of quality improvement initiatives, especially in resource-limited settings.


The way they run these studies is crazy to me:

>Only 3 of 22 operating stations (13.6%) had a functioning pulse oximeter prior to the intervention; accordingly, a pulse oximeter (model 7500; Nonin Medical Inc) was installed at each operating station as part of the implementation effort

The addition of essential medical equipment surely won't bias our results!

One could argue the essential medical equipment was missing due to lack of checklists ensuring its existence. That said, yeah, it would have been better to do 2 separate studies then: one on adding the equipment and then one on checklists.

> A number of studies found that they only help for a few months, while they're new.

Interesting, that kind of surprises me. Without going to research it right now, I wonder how/if the efficacy is affected by things like going through them in tandem with a partner, or doing them out loud or with exaggerated physical acknowledgements (like the Japanese train drivers who point out signs/notices along their route as a way to maintain focus on those notices).

A speculative hypothesis related to this (based on my own experience as someone who has read the Checklist Manifesto and is a big advocate for checklists):

Over time people internalize the checklists because they unwittingly conclude the reason for the checklist is to learn a new procedure rather than foolproof their procedures and avoid errors. As a result, they start to skip the checklist or get sloppy with it.

There are a couple other points related to this that I believe Gawande does address in his book:

1. Doctors (more generally experts or egoists) will be resistant to checklists because they find them unnecessary (given their experience or expertise).

2. Checklists need to managed with regular review and updates.

You can boil Gawande's book down to: "Start using checklists because they're really effective." But his book goes deeper than that and addresses some of the underlying human factors involved in getting an organization to use checklists effectively.

> Doctors (more generally experts or egoists) will be resistant to checklists because they find them unnecessary (given their experience or expertise).

At the end of Chapter 7 of Gawande's book (The Checklist Manifesto) is this revealing tale:


Nonetheless, some skepticism persisted. After all, 20 percent did not find it easy to use, thought it took too long, and felt it had not improved the safety of care.

Then we asked the staff one more question. “If you were having an operation,” we asked, “would you want the checklist to be used?”

A full 93 percent said yes.


So basically people stop doing checklists and then claim they don’t work. Checklists are great, but they have to be used. Instead of treating them as a learning process, I treat them as something I explicitly do not have to learn. It frees my mind for other things.

I don't know that this is the case. I was just speculating in response to the claim upstream that Gawande "chose to overlook the studies about how transient the benefit of checklists is." I too would like to see the citations. If there was a study showing this regression, I would be interested to see if it controlled for this sort of factor.

But I agree with you wholeheartedly. I don't want my mind cluttered with stuff that can be handled by simple script.

"Dropping protections because the failure rate dropped" is a common failure mode, as seen in: Checklists, vaccines, financial regulations, and I'm sure many more arenas.

That was the explicit justification for the Supreme Court finding that the Voting Rights Act wasn't necessary, from memory - states weren't doing the things it banned, so it wasn't necessary to ban them any more.

Makes me feel like there's a similarity between implementation of checklist methodology and implementation of agile methodology. Depends so much on culture and processes and people.

The other problems doctors have is there are many cases where people are different and so you deal with a situation not on the checklist.

While we're guessing, I would figure it just becomes drilled into people as automatic & a given, the same way you buckle your seatbelt without thinking about it.

> "The Checklist Manifesto" chose to overlook the studies about how transient the benefit of checklists is.

It's been almost a year now since I read this but I'm fairly certain Atul touched on this, either in this book or in his book "Better", that after those implementing the changes left, the departments often fell back into old habits.

Could this be the case?

This isn't just with checklists, but a typical behavior of organizations (at any scale). Organizations are systems, systems tend to fall into a steady state of performance, quality, etc. after some period of time. If you draw the people's attention to something (checklists, quotas, threats, praise, etc.) you can see a temporary boost in performance, but unless the culture changes the performance tends to return to that same steady state (maybe slightly enhanced or worse).

In order for the benefit to stick, you need to actually change the system. Otherwise, complacency or other things will return when the pressure and other early benefits wear off.

In other words it isn't having a checklist, it is actually checking that people follow the checklist. Note that follow the checklist is different from checking all items on the checklist which is an obvious work around to the requirement that you follow a checklist.

That's an interesting point, can you provide a link to those studies ?

Are these paper based? Any checklist apps out there for our daily use?

GitHub and GitLab support task checklists in Markdown and also project boards which add and remove labels like 'ready' and 'in progress' when cards are moved between board columns; like kanban:

- [ ] not complete

- [x] completed

Other tools support additional per-task workflow states:

- [o] open

- [x (2019-04-17)] completed on date

I worked on a large hospital internal software project where the task was to build a system for reusable checklists editable through the web that prints them out in duplicate or triplicate at nearby printers. People really liked having the tangible paper copy.

"The Checklist Manifesto" by Atul Gawande was published while I worked there. TIL pilots have been using checklists for process control in order to reduce error for many years.

Evernote, RememberTheMilk, Google Tasks, and Google Keep all support checklists. Asana and Gitea and TaskWarrior support task dependencies.

A person could carry around a Hipster PDA with Bullet Journal style tasks lists with checkboxes; printed from a GTD service with an API and a @media print CSS stylesheet: https://en.wikipedia.org/wiki/Hipster_PDA

I'm not aware of very many tools that support authoring reusable checklists with structured data elements and data validation.


There are a number of configuration management systems like Puppet, Chef, Salt, and Ansible that build a graph of completable and verifiable tasks and then depth-first traverse said graph (either with hash randomization resulting in sometimes different traversals or with source order as an implicit ordering)

Resource scheduling systems like operating systems and conference room schedulers can take ~task priority into account when optimally ordering tasks given available resources; like triage.

Scheduling algorithms: https://news.ycombinator.com/item?id=15267146

TodoMVC catalogs Todo list implementations with very many MV* JS Frameworks: http://todomvc.com

Reusable Checklists could be done with a simple text document that you duplicate every time you need it no ?

For sure. Though many tools don't read .txt (or .md/.markdown) files.

GitHub and GitLab support (multiple) Issue and Pull Request templates:

Default: /.github/ISSUE_TEMPLATE.md || Configure in web interface

/.github/ISSUE_TEMPLATE/Name.md || /.gitlab/issue_templates/Name.md

Default: /.github/PULL_REQUEST_TEMPLATE.md || Configure in web interface

/.github/PULL_REQUEST_TEMPLATE/Name.md || /.gitlab/merge_request_templates/Name.md

There are template templates in awesome-github-templates [1] and checklist template templates in github-issue-templates [2].

[1] https://github.com/devspace/awesome-github-templates

[2] https://github.com/stevemao/github-issue-templates

I really want slack to adopt these as well...

I'll often be on call with customer and create a checklist on MacOS Notes on the fly. Then will copy paste that in slack or github for simple tracking.

Mattermost supports threaded replies and Markdown with checklist checkboxes

You can post GitHub/GitLab project updates to a Slack/Mattermost channel with webhooks (and search for and display GH/GL issues with /slash commands); though issue edits and checkbox state changes aren't (yet?) included in the events that channels receive.

Kanban boards e.g. Trello, Kanbanflow, Microsoft Planner, and others. They all support checklists, and you can categorize/organize as you need.

“A simple, free and powerful way to manage your team's recurring checklists and procedures“ https://www.process.st/ Paid features include 3rd party integrations. (Disclaimer: neither a customer nor employee of the company.)

Do any of these let you re-use your checklists, though? Planner at least is pretty useless for this, as I don't think there is a 'reset all items to un-checked' feature, or even basic stuff like re-arranging your list.

Click the "..." and Copy Task. It will generate the checklist again without anything checked, then just mark the old as complete.

You'd need some system to mark when one list ends and the next begins, KanBan just treats them as individual tasks.

> even basic stuff like re-arranging your list.

All of them let you re-arrange your list. Is this a mobile specific issue?

Everything in my comment was describing Planner. You cannot re-arrange checklists on a task in Planner on mobile. And I'm not clear if you were describing Planner in your comment, but I just tested the workflow described and it results in a second copy of my task with the same checklist items checked.

> This is described in the book called "the checklist manifesto".

You might notice that the book was written by Dr. Gawande, who implemented the checklist in the fine article!

I second that, excellent book.

I've also read it, for anyone thinking about buying it, i think it can be completely summarised by:

'checklists are very very good. You should really use checklists'

Now if you require further info on why they are good, by all means read the book, i just found it was a blog-post, if not a tweet, expanded to a book, YMMV.

That's exactly what it was. Atul Gawande wrote a column in the New Yorker [0] and was presumably offered a deal to expand it into a book.

[0] https://www.newyorker.com/magazine/2007/12/10/the-checklist

> 'checklists are very very good. You should really use checklists'

If you stop at that you miss a big part of the book where he describes that not all checklists are equal, what makes checklists useful (i.e. you should not state the obvious in a checklist and he goes at length to explain why), and how you spread the usage of checklists in an organization. That's a lot more important than "checklists are very very good".

Plus the whole spiel about CRM (crew resource management), eg that the entire team should introduce themselves, that the nurse is as entitled to speak up and ask questions as the Prof. Dr. surgeon MD Esq., etc. etc.

That's the basic gist of all productivity and business how to/advice books. They're all a fairly simple set of ideas with 100 examples and testimonial style stories about just how revolutionary it is or how much it changed executive XYZ's life.

I think that you're right, yet the book may still be valuable. I have, for a while, read summaries of business (and other) books by getabstract.com. These cover the main points of the book, but what happens is that you read it, it all makes sense, and a day later you've completely forgotten of it.

The book, on the other hand, yes, expounds on the very same points again and again, with different examples, under different circumstances, highlighting different aspects, and then, having had the same message hammered home so many times, there's a faint chance that a month later you remember some of it.

(Great books change the way you view things forever, but that happens rarely, and never with business books, I'd say :-)

Yeah I'm not really saying it's useless just that it's the basic format of those books. I think the best way to read those is to skim the various testimonials to get an idea what they're talking about and get to the author's point then read them as they spark your interest or seem relevant.

I get why they're in there, it's one of the few ways to argue the actual effectiveness of whatever advice the author is giving. It just seems excessive sometimes how much of the books are just 'I swear this works look at these important people it worked for.'

Yes, and that's a feature. Human brains are swayed by narrative, not by rote facts. If you want to get a positive change implemented, you need to tell a story.

> I've also read it, for anyone thinking about buying it,

Or perhaps see if your local library has it.

I've reduced my book purchases, and generally only consider buying something nowadays if I still enjoy it after the second/third reading (from the library).

Buying a book before reading it is almost always a bad decision, even if it has rave reviews. And even if you love the book, owning it serves no practical purpose unless you constantly re-read it.

The only good thing is that they serve as visual reminders of the books that you've read; otherwise it's easy to forget the titles and authors.

> owning it serves no practical purpose unless you constantly re-read it.

I disagree. I write a lot on the margins of the books I own - notes, personal observations, questions, criticism. I highlight interesting passages. It helps me understand the book deeper and retain its ideas.

Note that rereading a book doesn't have to mean cover to cover. If you look things up in the book once in a while you should have it.

It doesn't need to be you who reads the book either, it could by your personal library and you lend it to friends interested in the same subject. Public libraries will get rid of unpopular books so having a personal library of obscure subjects you care about is useful. (The internet does not have everything)

> The only good thing is that they serve as visual reminders of the books that you've read; otherwise it's easy to forget the titles and authors.

It's possible to create an account on Good Reads or Library Thing to keep track. There's Delicious Library as well (for Mac?).

One additional thing I got out of it that wasn't totally obvious to me beforehand about checklists is that they work better if they don't attempt to be exhaustive. Focus on the major items that should be "checked".

I kindof agree, but he also had other interesting nuggets such as having all the medical staff introduce themselves and why they are there in the surgery room before any cutting begins.

It's interesting to think how often dumb errors can be caught just by making sure everyone in the room is there for the same surgery (i.e., repairing a joint, not cutting off a limb). Correcting that confusion before cutting makes me feel better.

The only addition I would have to that summary is:

"And yet, most people think checklists are beneath them. They are insulted that someone with as much experience as they currently have would require a checklist."

Can't tell you how happy it makes me to discover I'm not the only one who does this. My wife says it drives her nuts but I'm pretty certain she's also delighted by how we never forget anything before or during a trip.

We did something similar for example: left a tray of leftover food in the oven (turned off) just before a trip and came back to a pulsating surprise. I added "Check the oven is off and empty" to the list of things to do "Just before we leave" and it's never happened since.

That said, there are several hundred things on my generic version and it sometimes feels a bit daunting having to start afresh each time we travel but I think so far, it's been worth it.

I keep threatening to do a trip without it and see just how many things we forget, don't do and screw up. MAybe one day... :)

A 100 item checklist?

I just throw some stuff in a bag and worry less. Never fails. If I forget something it probably was not that important and I can just buy it at the airport / when I land.

Does your local airport sell passports and prescription medication?

I just fundamentally don't understand the statement, "If I forget something it probably was not that important". How does one follow from the other?

Man, if I was travelling to a different country and needed a passport AND forgot my passport, then I would agree with you. I guess my life is not so hectic that I don't forget the absolute necessities (you can't fly without that or you can die without that).

If you travel often but only sometimes to other countries the travel part becomes routine and the need for a passport can be forgotten.

I could see that being problematic.

My life is not that hectic and I often travel to other countries, yet I have forgotten my passport once and only once. Part of me thinks that once it happens it's very unlikely to happen again.

I still don't use a checklist for traveling, but I do use a to-do list religiously for...actual things to do. After this thread, I may just add a few more lists.

Passport. Credit Card. All you really need.

That's what I tell myself. If I can travel freely and spend money, don't have anything to worry about.

Oh... you don't have kids ;-)

obviously, that depends on the country. ;)

More seriously, when studying organization and lists in particular, I remember reading:

There are two types of list-makers - those who make them and use them, and those that make them and lose them.

If you're perpetually group #2, you're more likely to try it a few times then ditch the whole process.

Having 100 items on the checklist doesn't mean you need to act on all of them. You can go through your normal packing, then take a few minutes to scan through the checklist for anything you may have forgotten. Most items may be irrelevant to that trip. Just skip them.

This is my approach too. My time in the military got me into the habit of checklists for everything and I carried it over into my personal life for many years after I got out. I never forgot anything, but I was perpetually lugging around a ton of stuff the I never used.

It's been many years since I stopped worrying about it, and I've yet to have even a single instance come up where I forgot something important enough to be a real hassle.

Checklists are great for surgeons and pilots. The cost of missing something in those professions can literally be life or death. If I forget to pack something when I go on vacation, the most it could possibly cost me is money.

> If I forget to pack something when I go on vacation, the most it could possibly cost me is money

I was in an airline check-in queue behind some people who discovered they had left their passports at home. Cue near-coronary and marital strife. A relative had to break into their house and make a mad dash to the airport.

(I'm also a checklist person)

Yes, if I forgot my passport it might be a lot of money that it cost me. Maybe one day I'll forget my passport, but I rather doubt it. The exact same reasons that surgeons resist following an explicit checklist (which are terrible reasons if you're a surgeon) are perfectly fine for me because the stakes are much lower if I mess up, and in the mean time there are concrete benefits to winging it. It's a lot easier for those benefits to add up to be greater than then downside of a mistake when the mistake costs $2000 rather than someone's life.

I perhaps should have elaborated a bit about the number of items. It is broken up into sections like: * Do well before we leave: e.g. arrange insurance, book seats on flights. * Do just before we leave: e.g. engage window locks, turn off heating, empty dishwasher

Then sections for hand carry, electronics bag, wash bag, suitcase and various subdivisions within each.

I found the best way to manage it is to make one giant list so it might have a kite and a bucket and spade in the "misc items" for example. When we're planning a trip, I copy that list to a new place, edit the title accordingly and remove all the items I'm sure we won't need. Like the aforementioned kite and bucket if it's not a beach trip. Or the car pack with chargers, suction cup for phone navigation etc. if we're not renting a car.

I agree that it'd probably be mostly okay if I went rogue and I can always buy stuff in the airport or at our destination. Notable exceptions being medications, passports, credit cards. I still garner some measure of comfort from knowing we have everything even if getting there can be a little stressful.

> I keep threatening to do a trip without it and see just how many things we forget, don't do and screw up. MAybe one day... :)

I don't have a checklist, and usually I'm fine. So, it's certainly possible :)

Also, I think if you have a list of over 100 items, maybe it's time to simplify it or break it up into sublists. That length itself probably produces more anxiety than saved by the list. It sounds like an over optimization

For background, I create todolists and checklists all the time in my life. Just so far, I haven't felt the need to make one for taking vacations.

I don't know how I'd live without checklists and Trello boards. Just running a family with a couple of kids, I don't get how people used to do this.

Each kid has their own schedule, their own list of items they need that day, their own homework.

When you shop, you need to know what to get for everyone.

And there's the paperwork, you have to decide what to buy for major purchases and pay for them all, and you have to sign up to various things like voting registries and local tax.

Add to that your work, where you have a bunch of tasks to do as well, various projects, bugs, meetings, and so on.

I lived through the pre-mobile, pre-everyone-had-a-computer era, and I don't get how people did anything. Paper diaries? Rolodexes?

The best way to organize things is to not have so many things to organize.

People certainly are busier now, but they seem to be a lot less focused on important things.

Kids playing used to be spontaneously organized by the kids, or even organized in advance by the kids. The amount of available greenspace in a neighborhood seems to be a lot less now, and play appears to be monetized and organized by adults and organizations.

"The more you know, the less you need."—Aboriginal proverb

Read Samuel Pepys diaries from the 17th century. They're available online in various forms. It's fascinating both what has changed and what hasn't changed at all. Pepys wrote these diaries primarily for his own use and so he sends to be largely honest (at least as much as we are honest with ourselves). He describes cheating on his wife, lying to people and so on.

Anyway, Pepys complains frequently that his day's work was lost because he was not able to meet with someone in the expected place at the anticipated time. That's just how things were then, you could neither phone to ask "where are you?" nor to say "change of plan I will now be at the old bridge until 4pm".

Simpler life. Less productive.

Perhaps more time to wonder, explore, and waste.

Perhaps less fulfilling and more difficult to achieve goals.

paper calendars on the fridge was a big part of our home organization pre-computers. :)

People simply did less

>Paper diaries? Rolodexes?

Carbon based one, ie brain.

My own anti-anxiety strategy for thinking like making sure the cooker is off, windows are closed etc. is to take pictures with my phone of everything (of course I never look at the pics).

I suspect there might be an opportunity for a "visual checklist" app that prompts you to take pictures of stuff....

NB I do use a paper checklist for remembering to take stuff when I go up mountains at the weekend - forgetting gloves when it is snowing is never a good idea.....

Adding a physical act (in your case taking a picture) has been shown to DRASTICALLY increase the rates at which items are completed.

The classic example of this are train drivers: https://www.atlasobscura.com/articles/pointing-and-calling-j...

Quote from the article:

"Originally developed by the now-defunct Kobe Railroad Administration Bureau in the late Meiji Period (the early 20th century), pointing-and-calling is known to reduce workplace errors by up to 85 percent, according to one 1996 study."

One thing I do as a pilot, btw, is that for each item on the checklist I touch the actual control (and sometimes even activate on and off again, for example the alternate static air intake).

It serves several purposes:

* it ensures that you actually look and check, not just say the magic incantation ("fuel selector valve: BOTH") out of habit, and

* for rarely used controls (such as the alternate static air source), it familiarises you with it once per flight, so you don't fumble around in case you need it.

Not all pilots do that. I wonder whether there are studies on whether this helps. Certainly, there are many cases of planes crashing because pilots forgot to do certain items, even though they were on the checklist and the pilots have gone through the checklist.

https://en.wikipedia.org/wiki/Lufthansa_Flight_540 ("The flight engineer was found to have failed to open the slat system bleed air valves as required on the pre-flight checklist.")

https://en.wikipedia.org/wiki/Helios_Airways_Flight_522 ("the flight crew overlooked the pressurisation system state on three separate occasions: during the pre-flight procedure, the after-start check, and the after take-off check. During these checks, no one in the flight crew noticed the incorrect setting."

> it ensures that you actually look and check, not just say the magic incantation

This reminds me of https://en.wikipedia.org/wiki/Spanair_Flight_5022#Flaps_and_... ("In the Takeoff Imminent verification checklist the copilot had simply repeated the correct flap and slat position values without actually checking them")

I wonder whether there are studies on whether this helps.

There are for trains. Presumably, it generalizes for human behavior, even if it's a plane, not a train.


NYC Train conductors now do this, pointing to the video display overhead the center of the station when they open the window.

Here's a video of people having a bit of fun with it.


(New York City imported the practice from Japan)

I've used a packing list for travel for a while now. My current method is to set everything up with checkboxes, uncheck them all beforehand and then recheck them as I pack or as I decide I don't need them for this trip.

I used to just group items by category (outerwear, electronics, etc), but now I've found it better to group items by where they're going to be packed (pockets, under-seat backpack vs carryon / checked bag).

Below that, I have short supplemental lists for things like camping, international, trips with swimming/beach, formal (wedding, etc), or trips longer than a week.

Also, a "Before You Go" list that's stuff to remember when literally walking out the door (take out the trash, shut down home theater computer, etc) that isn't realistic to pack or do in advance. Still a work in progress, but it really helps free up mental energy.

I do almost the same, but the “Before You Go” list is a great addition. I’ve got a couple of different checklists in Trello for different kind of trips: week of snowboarding, long weekend with my wife, business trip to conference, camping with family.

Gosh - that is freakily like my approach on all counts. Are you sure you're not me :)

I am struggling with how to best organize the items within a section. You have given me some ideas. Thank you.

As a pilot, we use checklists in a solo flight differently than in a crew flight. I fly solo flights by “flows,” and then use/review the checklist at the completion of a flow to confirm I did not miss any step. In general the flows are a right-to-left arrangement of things you do in a certain phase of flight. That way you scan over the things in order and do/verify everything in a single “flowing” motion.

I have checklists for almost everything. Recently I’ve started worrying that I’m depending too much on them because I should be able to think up things I need to do without these checklists. As in I’m not engaging my brain as much. But your comment just made me realize that now I have the cognitive load to do things other than remembering tasks. I recently passed two licensing exams without being stressed out that a lot of my friends failed. And I think I may attribute my checklists habit to that.

(Shameless plug from a happy user: I rely heavily on the Things app for Mac and iOS)

I credit checklists for being much more creative in my work and personal life. An in-memory checklist is a huge distraction. Once you flush it to offline storage, you have more memory for other things, like thinking about how to solve the harder problems in life.

I wish I knew this when I was 30.

I spend a lot of time getting checklists together at work, mostly for other people, and then ruthlessly removing extraneous items from the list (usually by fixing unreliable things that are of the sort: step 5: Do X. step 6: double check that step 5 actually happened)

I get lots of credit for the former, but maybe one in five people see the latter as the bigger contribution.

We end up having to deal with things when we are tired. You have to make them so an idiot can do them, because some day you will be that idiot. All day exhausting meeting followed by a major emergency. Kid up half the night with a fever. New video game just came out. Bad dreams, whatever.

With regard to the difference between pilots and surgeons in this matter, it has been noted that the latter are not personally at risk from not using checklists. I am not suggesting that surgeons deliberately or cavalierly put patients at risk, but risk to oneself has a way of concentrating the mind.

There's an anecdote in The Checklist Manifesto which backs this up. I'm recalling from memory, so the details may be off, but when they tried to roll out a checklist program into a hospital, many of the surgeons resisted, feeling that it was insulting. After having used the checklist process for a while, this sentiment remained, but when surveyed "If you were going under the knife, would you want a surgeon who uses the checklist process", nearly all of the surgeons answered "yes". (when their own life is on the line, suddenly a checklist doesn't seem to repugnant)

Back in the 19th century, when Ignaz Semmelweis suggested that washing hands was a good idea, he met a lot of resistance. From wikiepedia, "Some doctors, for instance, were offended at the suggestion that they should wash their hands, feeling that their social status as gentlemen was inconsistent with the idea that their hands could be unclean".


Yep. What surprised me: certain things end up with surprisingly long checklists. My "monthly" checklist at home has 30+ items on it, and it's not padded.

When I hit 50 I started making lists like a mofo, because I realized it would relieve my cognitive load. And it did, big time.

I do this. Everyone seems to think I'm insane however. This is the same people who's lives regularly descend into chaos doing the same stupid things over and over again.

It reminds me on my Mom. Whenever we were traveling, she wrote a checklist. Very organized. I do it now too, helps me to offload.

I would likely forget something if I didn't have a travel checklist. Something I keep in my Evernote notebook called, wait for it, checklists :-)

They are especially handy when on multi-stop travel where I'm spending all my time worrying about the logistics of the travel and meetings. It has definitely saved me from losing a number of phone chargers and razors over the years.

I see the appeal and do it to some extent. However I haven't finalized on a system for it.

I've realized that there is quite a bit of overlap between some of my lists and have been thinking that I'd like it to be a modular system. A checklist consists of a any number of items and sublists so that one can quickly combine them.

For instance, travel might optionally include the sublist abroad and/or skiing or summer. A work-related trip might add another set of items etc.

I bet there are apps for this and I think I found a few when looking, but I'm afraid of the managing overhead and would like access to it on my phone and computers without cloud bloat. Maybe git + vim-wiki or something is good enough (would also work well enough on an android phone with termux).

Modularity; Software Engineering problems :)

In human computer interaction they often talk about the "gulf of execution" - when the desired end state is known but it's unclear how to get there.


I've found that using checklists helps tremendously when working on medium to large projects (things that take more than a weekend to complete).

For example, if I want to learn a new technology, maybe I'll get a book on python, add the list of chapters in my projects tracking document, and strike them off one by one.

That sense of steady progress helps tremendously.

Checkslists force me to really have some kind of plan for achieving a certain goal - how I want to achieve something. Because I have to be able to write down the single steps.

Also checklists make it very easy to just get started.. just begin with the first task

And last but not least - I use checklists especially for things that I do NOT want to do at all (but I will have to do anyway). I am already annoyed (for whatever reason) by that task - so I want to minimize the amount of time I have to spend dealing with it. Therefore I use a checklist with the minimal amount of necessary steps to solve that problem or task, so I can get rid of it as fast as possible.

Maintaining checklists in documentation for software design reduces mistakes dramatically. Writing step-by-step exacting build instructions for one of our core products reduced the annoying requests for help I got dramatically.

I also have a checklist for trips. But I haven't been able to come up with other use-cases in everyday life so far.

In my twenties, I kept medical appointments in my head for me and both kids a year out. I never saw any point in jumping through hoops to put it in a calendar. It struck me as a pointless time waster to write things down that I was going to remember without writing it down -- and then have to also keep track of the calendar, check the calendar regularly, etc.

My messy stacks of papers made me look disorganized, but I could find anything important within ten minutes. In contrast, we routinely tore the house apart for an hour looking for something of my husband's.

He liked to organize and file and alphabetize. But the things he failed to organize often ended up in a heap on the floor. He did all that because he couldn't keep track of it mentally.

If your life works without checklists, don't worry about it. But if you find you start overlooking important details as you get older/busier/in a new and unfamiliar situation, you might revisit the idea.

Just don't rain on someone else's parade. Check lists work well for many situations and are especially valuable when lives are on the line for some reason (or similarly critical situations where mistakes often happen for various reasons).

Agreed, checklists can become a cargo cult. Also, checklists don't always need to be written down; just systematizing some mental checks can be helpful enough (e.g. "phone-keys-wallet").

I just feel left pocket (phone), right pocket (keys), back pocket (wallet).

Habits -- the original checklist that predates written language.

I rely a lot on habits of that sort, which may be part of why I'm not big on lists for my own life.

I like to organise things in groups (for example, for paragliding I had 3 x 3 items, one for environment, equipment on the body, equipment "off" the body, respectively), or use mnemonics (before leaving plane: MaSeLToF (Main switch off, Sun guards set (and sun glasses removed from cockpit...), Logbook completed and hours noted, Tie down and chocks installed, Flight plan closed).


I have an extensive checklist for trips. I’ve also got a daily one, which is partially for helping me get the day started off right by checking off a bunch of easy tasks, and partially just to make sure I don’t miss something critical. Ever forget about a meeting you needed to prepare for until you got the meeting reminder? I have a daily checklist item to give my calendar a quick glance to make sure there’s nothing I need to prepare for. It only catches something maybe a few times a year, but that’s worth it for the 10 seconds it takes me every day.

Pretty much anything I have to do more than once, that involves more than a few steps, I make a checklist for. I take pictures sometimes, semi-professionally. I have a checklist for what to do before I take pictures (pack the bag, charge the batteries, clear the memory cards), and after (brighten teeth in pictures, remove lint/spots from clothes, pick photos to put in my portfolio). At work I have checklists for design tasks, some of which are things to do, some of which are things to consider (does this need a review from security? does this need additional monitoring?).

There are people that can keep all this stuff in their head. I’m not one of them and I know it. Having checklists reduces my anxiety levels by an order of magnitude.


  - Shopping lists
  - House errants (cleaning, maintenance)
  - Recurring payments (tax, power, water)
  - Car maintenance
  - Travel
  - Reading lists
  - Social (upcoming anniversaries, invitations, etc)
Work (I run a SaaS company):

  - Daily/weekly tasks
  - Tax filing
  - Deployments
  - Server health checks
  - Security checklists
edit: markup

Do you use any specialized software for that ?

I use Google Keep, because of easy sync between my devices. But I guess any text editor will do

Shopping lists are basically checklists.

In development, could be "pre-release/pre-push-to-production checks".

I've used them for video shoots too (e.g. pre-interview: "is camera charged? is extra battery on? are audio levels good? is frame ok? ND filter needed? took 10 second ambience audio sample? took b-roll?" etc.

We use checklists (to varying degrees of efficacy and adherence) at work. Obvious case: test procedures (for larger test cases and suites, not unit tests and automated tests). We also use them for things like peer reviews or releasing products to customers (to ensure we've asked the right questions, are releasing the correct product, have done all the things necessary to release the product, etc.).

Given that any routine could be made into a checklist, it seems likely that you have lots of everyday checklists that you do a good (or good enough?) job of keeping track of in your head.

Maybe for most things that you could use a checklist for, the effort just isn't worth it?

This is almost certainly the case. Consider the "simple" act of taking a shower and how internalized it is for most people.

If I remember anything from the "Getting Things Done" training is precisely this:

Writing down tasks saves you a lot of brain cycles and also removes worries, as otherwise you have to be constantly "refreshing cache" on pending tasks to not forget about them.

What do you have on the travel check list? Everytime I travel I say to myself that I should make a list but always forget or put it off.

Is there a good app for storing/sharing various checklists (travelling checklist, selling house checklist, etc.)?

I use the Things app. It allows you to have Projects Area with project inside (collapsible). The checklists inside can have sub-checklists. The sub-checklists can be marked “done” with a check mark or marked “not needed” with a cross. projects have headings so you can organize different tasks in that project.

Things only stores checklists. Doesn’t share them.

TickTick is my favorite.

Google Keep.

I recommend Dynalist or Workflowy

You don't know what you can't remember

Why care if dishwasher is empty?

I get the point of checklist for critical process. But I think it's counterproductive to drone your life away following task lists full of feature creep.

First with a little training you can put mental reminders in your mind, trusting yourself that they will show up when needed. It also helps with keeping your brain and memory in good working condition, and force you to stay in mental clarity and not being so overworked and tired that you have to rely on external list.

Second it's not robust to rely 100% on a task list being completed, sometimes forgetting something means that it's not that important. It's more important to rely on situational awareness to know what's need to be done and in what priority. The logic behind is pick something from the hot mess and make the whole better.

Third we can automate and delegate more easily now, quite often if you need to use a checklist, a script would be even better.

Think the "Checklist Manifesto" addresses your creep and clutter as basically a very bad design. In the book they went over several medical checklist iterations before they struck something sensible that improved conditions and saved lives. Most importantly, they changed culture in places to where a nurse was allowed to tell a doctor "no" without fear of reprisals, and re-framed checklist items to pay attention to a time window for administering antibiotics, not just whether a patient received them. The checklist that's helpful should fit on a laminated index card and it should list critical things. But, it's hard to distill the essence of something and most checklists end up as a loose thought vomit on pages.

I work on software related to medical drilling. Nurses run through simulations (mostly a situation where something has gone wrong) and get graded.

It baffled me to learn that this is NOT the norm at hospitals. Due to the stress of a situation-gone-awry and inexperience, some horrific things can happen.[0][1] In some situations you may only have a few minutes to enact corrective procedures. In any case without checklists (and without experience from running routine simulations) it's very easy to make mistakes or forget what to do.

I thought the checklists themselves were standard but it appears not...? The more I learn about hospitals' operating practice the more wary I become. I have no idea why hospitals aren't like the aviation industry and have checklists and expiring certifications. (Or maybe I heard wrong and I'm just completely wrong here.)

[0]: https://www.telegraph.co.uk/news/2018/05/10/premature-baby-d...

[1]: https://www.nbcbayarea.com/news/local/Dental-Anesthesia-Unde...

> Mead said the principal risk is a patient’s airway. He explained that a child’s breathing tube can collapse without warning under sedation.

> “It happens instantaneously,” he said. “You have maybe half a minute to make critical decisions about how you're going to manage that child's airway. You can't do that if you don't have somebody competent there helping you.”

I was part of a start-up developing checklist for high risk pregnancies. The checklists were developed by some of the best doctors in the country, who had already proved the worth of using checklists in their own practice. Even with all of that, we had unending push back from every single hospital we talked to. Eventually it killed the company because deals could not be closed. I still hear of hospitals saying they want checklists, and they keep saying that until they see one, and then they don't want it anymore.

Also, it wasn't a cost issue. The package was pretty cheap all told. The push back was in the "system getting in the way"...which was kind of the point unfortunately.

Atul Gawande talks about the importance of developing checklists collaboratively with the people who will use them as opposed to imposing them top down.

Many procedures in hospitals are checklist-driven. Peter Pronovost had an early, high-impact publication on the topic of bloodstream infection prevention with checklists: https://www.nejm.org/doi/full/10.1056/NEJMoa061115

I was surprised too, I worked on software for Surgery checklists a decade ago and thought it was standard practice and that only our digitization of it was new, the effects of a checklist have been known for quite a while now. The software I worked on would track every instrument and screw taken into a theatre (using hand scanners), the doctor would have his list of steps for the procedure and the equipment necessary, standard emergency packages were available for the exceptions, etc. It's not just for the direct patients either, some disease can survive instrument sterilization so knowing who else they've been used on can be important.

In the aviation industry pilots rarely get sued personally. IMO, the issue is more about legal system than it is about the medical one.

In the aviation industry, lawsuits aren't necessary. If a pilot makes a serious enough mistake, he dies. If we executed doctors when their patients died, lawsuits would be the least of their concerns.

If a pilot makes a mistake, he'll either die or lose his licence. Either way, his life is ruined.

> If a pilot makes a mistake, he'll either die or lose his licence.

I have a private pilot license. This is not true at our level, and is very often not the case at the big companies. Everyone makes mistakes; firing all the mistake-makers would not end well.

One of the reasons aviation is so safe (excluding corporate coverups like what happened a couple of times with Boeing) is that there is an emphasis on learning and making sure that mistakes never happen again - to you or to other pilots.

One of the exams for the Light Aircraft Pilot License for sailplanes in Europe has the multiple-choice question "Why is safety improved by submitting an official report of safety-related incidents?", where one option is "because then we can revoke the licenses of unsafe pilots", and another is "because then we can collectively learn from dangerous situations". Spoiler alert, the latter is the correct answer.

I can't speak for professional aviation, but I would be very surprised if the safety ethos isn't similar. Ruining a career after a mistake only leads to covering up mistakes. Why the hell is this a systemic problem at all? It's obvious it won't work.

No it's not. Career =/= life.

Most pilots would feel pretty bad if they survived a crash that was fatal to their passengers.

Because they're dead? Surgeons don't have that much of their own skin in the game...

If anything that sounds like a great reason for a doctor to use an industry standard checklist. "See exhibit A, documenting that my client followed the proper procedures". Not that that necessarily sounds great for patients with legitimate suits but for doctors it sounds useful.

Yep, so they'll fill the checklist beforehand just to make sure they're covered...

The solution may be found in the legal system and its corresponding arm, the malpractice insurers, if both were to mandate a minimal standard of care including the use of checklists.

I agree with the first part, but not with your conclusion.

There is way too much litigation. Hospitals and staff are using defensive legal strategies-- obscuring docs, discouraging internal (written) investigation, delaying urgent treatment with unneeded consultation (to get more signatures on a decision).

IMO, there should be legal protection against malpractice lawsuits. Increasing the attack surface will not help with the core problem:

Doctors are over-worked, they are human and they make mistakes. The solution is to either enforce work conditions for doctors (and people die) or accept those mistakes (and people don't get money when they are on the wrong side of statistics)

So who else should be untouchable?

What purpose does suing anyone for anything serve?

I don’t see too many doctors demanding to become employees (with far less personal liability) instead of independent contractors as they usually are. Getting the best of both worlds is asking for a lot.

I didn't mean to say that they should be "untouchable". Only that they should be given some protection for some very human, systematic, (unavoidable?,) mitigating factors

One of the issues I've seen in implementing checklists is actually the urge of people to put extreme detail into the checklist and people not putting items in a reasonable order. If you look at the referenced checklist (https://apps.who.int/iris/bitstream/handle/10665/44186/97892...) it is a very approachable list that acknowledges good skill in the people involved. Note that the "before patient leaves" checklist mentions the sponge count but the pre-incision checklist does not. That's because a sponge count is simply part of the job of an instrument nurse and something they always do when they open a pack of sponges.

It's also hard to insert checklists into established procedures. One thing you could do is attach them to important parts that are not allowed to be used until you read the checklist. For example, you could refuse to unwrap the main surgical pack until the pre-incision checklist is followed. Pharmacy could wrap the anesthetic induction drug in the first checklist. The surgeon could be responsible for signing the final checklist in order to get paid.

Keep checklists simple, use them every time. Put them in places where they have to be used.

Wise cautionary note. Use the right tool for the job.

Back when we used to burn "golden" CD-ROMs for releases: Our checklists were getting too unwieldy, we were still making mistakes.

So I started a Go/NoGo process, aka Roman Evaluation. Any one could stop the release for any reason. We'd fix the problem(s) identified, try again the next day.

(Of course, we fed each release's results back into process during the post mortems.)

Sounds more like TPS model.. "Build a culture of stopping to fix problems, to get quality right from the start. (Jidoka)" [https://en.wikipedia.org/wiki/Toyota_Production_System]

I haven't heard of the term "Roman Evaluation". Where does it come from?

Huh. Because we used thumbs up or down, we called it Roman Evaluation. But that's probably wrong. Releases required unanimous approval. aka blackballing https://en.wikipedia.org/wiki/Blackballing

And here is the checklist [1]

These seem like very common-sense things to check - Is this the right patient? Are the instruments sterile? Have we counted all the surgical equipment after the procedure?

[1] https://apps.who.int/iris/bitstream/handle/10665/44186/97892...

Maybe so. When was the last time you forgot to do something that was "common-sense"? Forgot to pick up your coat after work? Left your wallet on your desk? Now imagine each of those mistakes was fatal for a patient.

The issue is in the margins.

Maybe a shift-change caused the surgical team to be different from normal, so people aren't as comfortable with each other. There's social/professional pressure to fit within a hierarchy, especially with new people. Maybe a few people lower on the totem pole think something might be off, but don't want to say anything lest they risk appearing to undermine the surgeon.

So, at first it appears that a whole room of people would need to independently make the same mistake. But that's not so; only a few critical people need to make the mistake, and with enough ambiguity in the process (easily caused by anything happening 'out of the ordinary'), it won't be corrected some percentage of the time. Even seemingly trivial things.

The FAA found this occurring in the cockpit, especially from the '3rd seat'. A pilot and first officer may be 'in the weeds' dealing with the immediate threat of a situation, whereas others have the benefit of distance to reflect on a situation and observe more clearly. They don't get tunnel vision, and are in a better place to diagnose a tricky problem. However, they may not feel empowered to speak up, or feel they don't have the information the pilots do. Aviation has, broadly, sought to correct this and encourage anyone to speak up. Recently, this happened during the flight before the Indonesia 737 crash where similar AoA/MCAS issues occurred, but a 3rd pilot helped to address the situation.

It's always worth remembering that "after" can be after 10+ hours of continuous high-stress concentration, so remembering lots of little things can be very challenging.

Thanks, I can't believe this wasn't in article. The BBC might need a checklist of their own.

1. If the article is referencing a document, video, or picture, is it linked/embedded?

[ ] Yes [ ] Not available [ ] Not applicable

2. If the document refers to a third party report, is it linked?

[ ] Yes [ ] Not available online [ ] Not applicable

3. Are background sources linked to high-quality, external sources?

[ ] At least 3 links present [ ] We sat there for 1 minute and couldn't come up with anything that needs linking

4. Are needless generic internal links to category/tag pages etc. removed?

[ ] Yes

This is pretty interesting.

There seems to be a whole other list referenced: "Is the anaesthesia machine and medication check complete?"

Also the team are supposed to intro themselves along with their roles. I wonder if it often happens that someone is missing?

I'd bet more often it's two people who could each do the other's role and therefore wanting to be specific that one person is responsible for X and the other Y.

That's the sign of a good checklist. The idea is to free up mental processing to focus on harder issues. Let the doctor focus on the hard stuff and not spend excess time trying to remember the simple stuff.

As a life long patient, while I appreciate the checklists, I think some of the repeated rechecking is a bit much.

.... They haven't been using checklists? I've been getting so upset at the medical community recently. Pilots solved most of these problems decades ago. We've been trying to help them figure out these tools that we developed to save lives, but it seems like things are only changing one funeral at a time.

"500yr of progress being held back by 500yr of tradition" is highly applicable to the medical profession. There's a lot of arrogance floating around the medical profession as well that tends to put a damper on anything that might reduce human error.

Surgeons don't need checklists because they don't make mistakes, unlike those filthy three dimensional bus and truck drivers. /s

This explains why the American Medical Association is a top lobbyist.

Instead of adapting, they legislate.

And the fantasy that Physicians are unfailing experts leaves you after a you regularly interact with them.

I have had the same experience in other countries too, not just the U.S

Medical profession really comes across as arrogant and know-it-all, at least in my experience

> "500yr of progress being held back by 500yr of tradition" is highly applicable to the medical profession.

Is that true of most professions? The difference being we only really care when lives or large quantities of money are at stake. Probably more the later and less the former unfortunately.

Nobody cares what the skilled trades do. Tradition for the sake of tradition doesn't really get in the way of preventing human error in software, accounting or engineering.

Cops and doctors (in that order) seem to be the biggest offenders when it comes to rejecting process improvements to the detriment of society but there's definitely others. It's not a binary value.

>Pilots solved most of these problems decades ago.

In the safest planes (commercial airliners), pilots have systems recording their control inputs, and these can be used to directly attribute damage to/loss of the airframe to pilot malfeasance; the shame of a clear screwup will be clearly documented and in most cases, divulged to the public.

Medical professionals, on the other hand, seem to face a lower standard of accountability simply because it's truly far more difficult (if not impossible in some cases) to monitor all the variables associated with treating a patient compared to monitoring human-designed systems. I have to wonder if this epistemic quagmire where cause and effect are not necessarily tracked (and in some cases, not even truly understood) leads to a mindset that is more willing to write off negative outcomes as the result of external factors (comorbidity, patient age, patient adherence to physician instructions, even pure luck/probability) than tackle the tough problem of correlating personal behaviors and actions to distinct outcomes.

It's not hard to record all patient-doctor interactions. But it is almost certainly illegal in most jurisdictions, supposedly for patient privacy reasons.

That this also helps making doctor mistreatment claims hard to prove is hopefully an unintentional side effect. But you have to wonder...

Unfortunately, there's a lot of resistance to using checklists, from the nurses to doctors. I wish they'd just swallow their pride and worry more about how to improve than how it makes them look when their mistakes become visible and explicit to the people around them.

This is something of a case of "Physician - heal thyself".

I've advocated the use of checklists in software for decades. I wrote something 5 years ago and posted it here[0][1]. The discussion was enlightening. Read the discussions, keeping in mind the comments here about the resistance encountered by people in the field.

Many of the points in the discussions are useful and can be used to create and adapt checklists, but no, they are being used to dismiss them out of hand.

Checklists? We don't need to stinkin' checklists.

I've given up and just use them in my companies.

[0] https://news.ycombinator.com/item?id=7655018

[1] https://news.ycombinator.com/item?id=18522627

Reminds me of the old you are not done yet list. Couldn't track the one I'm thinking of down but found this: http://www.thebraidytester.com/downloads/YouAreNotDoneYet.pd...

I feel like I could use a checklist or two.

Only one company I worked with to date really used checklists and I firmly believe it was one of the reasons they were able to maintain 150k LOC of legacy JavaScript in a single project.

One of the others was testing furiously.

I wonder how much of this is due to the self-selection of the profession in terms of personalities. Surgery in particular is known to attract Type-A personalities. I witnessed similar attitudes in healthcare and other high-status positions where hubris makes them think they know better...until they have an accident. And even then, there's a strong urge to rationalize the outcome as unavoidable

Visible mistakes generate lawsuits. There used to be more processes, removing them was generally a legal necessity.

It's not just about lawsuits. I've seen cases (hospitals) where checklists drew pushback from doctors because they didn't like being questioned by nurses who noticed them making mistakes. It impinged on their egos. Implementing checklists requires a certain amount of humility that just isn't there in many cases.

They have been using checklists. This news is that they've measured how much harm has been prevented. It's the first country (Scotland) level research.

> The findings, reported in the April 17 British Journal of Surgery, are based on an analysis of 6.8 million operations performed between 2000 and 20014. The Surgical Safety Checklist was introduced in Scotland in 2008 as part of the Scottish Patient Safety Programme, and by 2014 the rate had decreased by 36.6 percent over six years to 0.46 deaths per 100 procedures. Researchers noted that this fall in death rates was not seen in patients who did not have surgery.

I read in this New Yorker article that Spain introduced checklists in 2007. Does anybody know the results of checklists there?


The medical community uses checklists. They've been using checklists for a while. A number of studies found that they only help for a few months, while they're new.

That said, "the medical community" is not a homogeneous monolith, and you can absolutely find regional variation in what checklists are used for, how detailed they are, how closely they're followed, how people are accountable for keeping to them, etc.

>I've been getting so upset at the medical community recently


Don't confuse media narratives with what's actually going on in the medical community. It's a sure-fire way to get (a) upset, and (b) entirely misled. Medical science has been a major target for media FUD for ages.

I think part of the reason pilots are so diligent is that it's their own lives on the line too...

I have been in hospitals and seen them going through checklists with my own eyes. I don't think your assumption is completely accurate. Maybe it depends on the health system, the procedure, or the facility.

They have, since 2008. You're right about pace though, unfortunately rolling out change into bureaucracy is painstakingly slow.

I find it very concerning, using a checklist seems like common sense.

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