Beyond the Checklist

Beyond the Checklist

Authors: Suzanne Gordon, Patrick Mendenhall, Bonnie Blair O’Connor


What lessons should healthcare really learn from aviation safety? What ‘major cultural and behavioural shifts’, beyond checklists and briefing protocols, define aviation safety? (page 9). This book is about the core aviation values which, the authors stress, have been overlooked by the medical world. They illustrate these values very early in the book with the striking example of Chesley Sullenberger, the pilot who successfully landed US Airways Flight 1549 on the Hudson river, after it was hit by a flock of geese. The book sees this as ‘… the direct result of a concerted effort to make flying safer by refining communication and teamwork…’ (page 2). Admitting that checklists are ‘…the only way to be absolutely certain that a particular job is done’ (page 129), the book shows that safety goes beyond these.

Feedback checklist. AJ Cann on Flikr.
Feedback checklist. AJ Cann on Flikr.

The authors were critical of the ineffectual efforts that healthcare has made to become ‘a truly high-reliability industry’. They says these efforts are ‘… much more lip service than real systemic change…’ (page 9). They criticise the nature of hospital teams which are composed of members who ‘… do not share a common mental model, assumptions, or information about what is and is not harmful to patients’ (pages 5). Rather, they say, healthcare teams are characterised by ‘…disrespect, historical antipathies, and even outright abuse…’ (page 185).

110910-N-8377A-035. ResoluteSupportMedia on Flikr.
110910-N-8377A-035. ResoluteSupportMedia on Flikr.

The authors were particularly disapproving of the heroic medical model which physicians inherit and ‘…pass on to new cohorts and generations…’ (page 180). The authors were scathing of books written by physicians which promote the doctor as the most important member of the health team. These books include Jerome Groopman‘s How Doctors Think, and Atul Gawande‘s Complications, Better and The Checklist Manifesto (pages 180-181). They argue that ‘…the commonly held physician-centric view of the health care enterprise is a serious inhibitor to the kind of teamwork upon which consistently safe patient care depends…’ (page 181).

The book’s clear focus is teamwork (page 8). The authors point out that in aviation, team members ‘…think, decide, act and learn together…’ (page 2). This is the concept of distributed cognition (page 11). They explore the behaviours that characterise good teams such as introductions, team briefings, creating a shared language, and conceptual clarity. They discussed other essential features of teams such as inquiry, advocacy, and assertion (page 96-97). The book lists the five conditions of successful teams with reference to sociologist J Richard Hackman (page 81). It also lists the characteristics of effective team leaders such as their capacity to express vulnerability, and their ability to project secure authority (page 87 to 89).

The book also covers the subject of communication quite extensively. The authors explored the four-point guide to effective communication (page 55), and the ten lessons of crucial conversations (page 75). They covered non-verbal communication (page 50) and assertiveness (pages 58-59), and they emphasised the importance of ‘predictable communication patterns’ (page 45). The book highlights the hazards of poor communication including loss of situation awareness (page 46). Other topics covered by the book include stress management, fatigue, delegation, and task prioritization.

By Ghozt Tramp [CC BY-SA 2.0], via Wikimedia Commons
By Ghozt Tramp [CC BY-SA 2.0], via Wikimedia Commons
The book used illustrative examples to show how healthcare may adopt the true lessons of aviation safety. The Osher Clinical Center, for instance, is a lesson in how to successfully implement an effective team approach to patient safety. The Maimonides Medical Center on the other hand shows how a code of mutual respect overcame typical adverse healthcare attitudes such as ‘…belittling, shaming, blaming, and even abusive behavior…’ (page 72).

The authors also used anecdotes to support their arguments. An example is the crash of United Airlines 173 in 1978 which they said was a defining moment in aviation safety (page 15-16). They traced how this led to the dismantling of the harmful hierarchy and cockpit culture of the time. Another example is the KLM-Pan Am crash at Tenerife in 1977 which illustrates the dangers of poor communication, and of using ‘nonstandard terminology‘ (page 23).


This book brings a fresh perspective to the concept of teamwork, and it critically looks at the place of doctors in teams. It contains a lot of useful information and addresses many subjects, but this comes at the risk of losing focus of the most important themes. The authors have however extracted the most important safety lessons from aviation, and they have demonstrated how important these are to healthcare safety.


This is an excellent review of healthcare safety, looking beyond protocols and addressing the whole culture of medicine. It is essential reading because it provides important insights for doctors and healthcare. The ‘heroic medical model’ symbolises the concepts that influence patient safety, and these go ‘beyond the checklist’. I recommend this book to every doctor.


Publisher, Place, Date: Cornell University Press, Ithaca, 2013
Number of Chapters: 11
Number of Pages: 261
ISBN: 978-0-8014-7829-1
Price: £15.50
Star rating: 5


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