Thursday, April 17, 2014

The checklist manifesto works. Except when it does not!

My plan was to fill gas at one of the regular gas stations where I stop.  The gas gauge made it clear that there wasn't enough fuel in the tank.  With my eyes on the road, I reached into my bag for the wallet.

No wallet.

Perhaps in the computer bag?  My hands crawled in the ouch pouch there.

No wallet.

In my mind, I replayed the day.  There was only one possibility--the wallet was at home.  The home that I was driving towards.

But, not enough gas.  For sure.  There was a fair chance that I would reach home.  But, what if I don't make it?  It is not like I can pull into a gas station and fill up--no wallet to pay for the gas.  Even worse, if a cop stopped me for whatever reason, I will be in even more trouble for driving without a valid licence!

I continued driving.  Constantly doing the math on how many miles remained.  And scanning for patrol cars.

I wondered how this happened.  I had to figure this out.

To understand what went wrong is an important part of life.  Way back, when we were kids, my siblings and I loved going to the local outdoor club to watch movies every week.  Every once in a while, before the movie began, they ran short films, some of which were almost like public service announcements.  It being an industrial town, one of the short films was about industrial safety. The film was done with great humor, with a clear bottom-line: accidents do not happen, but are caused.

Not having the wallet with me was also an accident.  How did it happen?

It did not take much to solve the mystery.  I had somehow forgotten to do one thing that I always did before I drove out of the garage.  This one time I forgot and it messed me up.  I forgot to do my mental checklist.

I had my own checklist system to make sure I was not forgetting anything, and this became even more rigorous a habit after reading Atul Gawande's essay in the New Yorker a few years ago.  In the context of medical care, Gawande wrote:
The checklists provided two main benefits, Pronovost observed. First, they helped with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic events. (When you’re worrying about what treatment to give a woman who won’t stop seizing, it’s hard to remember to make sure that the head of her bed is in the right position.) A second effect was to make explicit the minimum, expected steps in complex processes.
My regular life checklist approach, therefore, got reinforced.  After pulling out of the garage, the routine was to press the remote to close the door, and then run through a series of checks: gas gauge, work bag, lunch and snacks, water bottle, wallet, cellphone.  It worked very well.

Except this one time when I had forgotten to go over the checklist itself.  Which is why I didn't realize that I didn't have the wallet with me.

Which means I now have a new problem.  How do I make sure that I have gone through the checklist routine?  A checklist for the checklist itself?

I turned into the driveway.  The gas gauge light lit up to indicate that I didn't have even fifteen miles left.  I didn't worry anymore--I pressed open the garage door and I was safely home.

End of the blog post?  Check!

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