The first is ignorance—we may err because science has given us only a partial understanding of the world and how it works. (Location 125)
Tags: failure
The second type of failure the philosophers call ineptitude—because in these instances the knowledge exists, yet we fail to apply it correctly. (Location 126)
Tags: failure
But now the problem we face is ineptitude, or maybe it’s “eptitude”—making sure we apply the knowledge we have consistently and correctly. (Location 147)
Failures of ignorance we can forgive. If the knowledge of the best thing to do in a given situation does not exist, we are happy to have people simply make their best effort. But if the knowledge exists and is not applied correctly, it is difficult not to be infuriated. (Location 168)
Tags: failure
One needs practice to achieve mastery, a body of experience before one achieves real success. And if what we are missing when we fail is individual skill, then what is needed is simply more training and practice. (Location 179)
Tags: experience
the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us. (Location 190)
Tags: knowledge
The ninth edition of the World Health Organization’s international classification of diseases has grown to distinguish more than thirteen thousand different diseases, syndromes, and types of injury—more than thirteen thousand different ways, in other words, that the body can fail. (Location 249)
Tags: stat
The test pilots made their list simple, brief, and to the point—short enough to fit on an index card, with step-by-step checks for takeoff, flight, landing, and taxiing. It had the kind of stuff that all pilots know to (Location 429)
In a complex environment, experts are up against two main difficulties. The first is the fallibility of human memory and attention, especially when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events. (Location 450)
Tags: memory failure
Faulty memory and distraction are a particular danger in what engineers call all-or-none processes: whether running to the store to buy ingredients for a cake, preparing an airplane for takeoff, or evaluating a sick person in the hospital, if you miss just one key thing, you might as well not have made the effort at all. (Location 453)
Tags: memory failure
Checklists seem to provide protection against such failures. They remind us of the minimum necessary steps and make them explicit. They not only offer the possibility of verification but also instill a kind of discipline of higher performance. (Location 459)
Tags: discipline, checklists
These checklists accomplished what checklists elsewhere have done, Pronovost observed. They helped with memory recall and clearly set out the minimum necessary steps in a process. (Location 498)
Tags: checklists, memory
Checklists, he found, established a higher standard of baseline performance. (Location 501)
Tags: standards
Four generations after the first aviation checklists went into use, a lesson is emerging: checklists seem able to defend anyone, even the experienced, against failure in many more tasks than we realized. They provide a kind of cognitive net. They catch mental flaws inherent in all of us—flaws of memory and attention and thoroughness. And because they do, they raise wide, unexpected possibilities. (Location 596)
Tags: memory failure
Two professors who study the science of complexity—Brenda Zimmerman of York University and Sholom Glouberman of the University of Toronto—have proposed a distinction among three different kinds of problems in the world: the simple, the complicated, and the complex. Simple problems, they note, are ones like baking a cake from a mix. There is a recipe. (Location 600)
Complicated problems are ones like sending a rocket to the moon. They can sometimes be broken down into a series of simple problems. But there is no straightforward recipe. (Location 604)
Complex problems are ones like raising a child. Once you learn how to send a rocket to the moon, you can repeat the process with other rockets and perfect it. One rocket is like another rocket. But not so with raising a child, the professors point out. (Location 606)
of complex problems: their outcomes remain highly uncertain. Yet we all know that it is possible to raise a child well. It’s complex, that’s all. (Location 610)
Man is fallible, but maybe men are less so. (Location 838)
Tags: quotes
It spelled out to the tiniest detail every critical step the tradesmen were expected to follow and when—which is logical if you’re confronted with simple and routine problems; you want the forcing function. (Location 903)
confronted with complex, nonroutine problems—such (Location 906)
The philosophy is that you push the power of decision making out to the periphery and away from the center. You give people the room to adapt, based on their experience and expertise. All you ask is that they talk to one another and take responsibility. That is what works. (Location 907)
Tags: management, responsibility
It’s simply the definition of a complex situation. And such a situation requires a different kind of solution from the command-and-control paradigm officials relied on. (Location 945)
management. “A lot of you are going to have to make decisions above your level. Make the best decision that you can with the information that’s available to you at the time, and, above all, do the right thing.” (Location 949)
Tags: management
the real lesson is that under conditions of true complexity—where the knowledge required exceeds that of any individual and unpredictability reigns—efforts to dictate every step from the center will fail. People need room to act and adapt. (Location 983)
Yet they cannot succeed as isolated individuals, either—that is anarchy. Instead, they require a seemingly contradictory mix of freedom and expectation—expectation to coordinate, for example, and also to measure progress toward common goals. (Location 984)
That routine requires balancing a number of virtues: freedom and discipline, craft and protocol, specialized ability and group collaboration. And for checklists to help achieve that balance, they have to take two almost opposing forms. They supply a set of checks to ensure the stupid but critical stuff is not overlooked, and they supply another set of checks to ensure people talk and coordinate and accept responsibility while nonetheless being left the power to manage the nuances and unpredictabilities the best they know how. (Location 988)
Tags: collaboration, checklists
Note: Checklists ensure that tasks are not over looked and also ensure people talk and take responsibility
So just as a little test, buried somewhere in the middle of the rider, would be article 126, the no-brown-M&M’s clause. “When I would walk backstage, if I saw a brown M&M in that bowl,” he wrote, “well, we’d line-check the entire production. Guaranteed you’re going to arrive at a technical error. . . . Guaranteed you’d run into a problem.” (Location 1003)
Tags: anecdote
Thinking back on the experiment, I was fascinated to realize that it was as much a checklist study as a soap study. So I wondered: Could a checklist be our soap for surgical care—simple, cheap, effective, and transmissible? (Location 1216)
Reznick had never heard about the demise of Master Builders, but he had gravitated intuitively toward the skyscraper solution—a mix of task and communication checks to manage the problem of proliferating complexity—and so had others, it turned out. (Location 1259)
Their insistence that people talk to one another about each case, at least just for a minute before starting, was basically a strategy to foster teamwork—a kind of team huddle, as it were. So was another step that these checklists employed, one that was quite unusual in my experience: surgical staff members were expected to stop and make sure that everyone knew one another’s names. (Location 1342)
Tags: collaboration, communication, teamwork
There have been psychology studies in various fields backing up what should have been self-evident—people who don’t know one another’s names don’t work together nearly as well as those who do. (Location 1349)
Tags: collaboration, communication, teamwork
The researchers called it an “activation phenomenon.” Giving people a chance to say something at the start seemed to activate their sense of participation and responsibility and their willingness to speak (Location 1355)
Tags: communication, teamwork
It had three “pause points,” as they are called in aviation—three points at which the team must stop to run through a set of checks before proceeding. There was a pause right before the patient is given anesthesia, one after the patient is anesthetized but before the incision is made, and one at the end of the operation, before the patient is wheeled out of the operating room. (Location 1392)
Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat the people using the tools as dumb and try to spell out every single step. They turn people’s brains off rather than turn them (Location 1495)
Tags: favorite, checklists
Good checklists, on the other hand, are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything—a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps—the ones that even the highly skilled professionals using them could miss. Good checklists are, above all, practical. (Location 1497)
Tags: checklists, favorite
Pilots nonetheless turn to their checklists for two reasons. First, they are trained to do so. They learn from the beginning of flight school that their memory and judgment are unreliable and that lives depend on their recognizing that fact. (Location 1507)
You must define a clear pause point at which the checklist is supposed to be used (unless the moment is obvious, like when a warning light goes on or an engine fails). (Location 1529)
Tags: checklists
You must decide whether you want a DO-CONFIRM checklist or a READ-DO checklist. (Location 1530)
With a DO-CONFIRM checklist, he said, team members perform their jobs from memory and experience, often separately. But then they stop. They pause to run the checklist and confirm that everything that was supposed to be done was done. With a READ-DO checklist, on the other hand, people carry out the tasks as they check them off—it’s more like a recipe. So for any new checklist created from scratch, you have to pick the type that makes the most sense for the situation. (Location 1531)
Tags: checklists
The checklist cannot be lengthy. A rule of thumb some use is to keep it to between five and nine items, which is the limit of working memory. (Location 1534)
Tags: checklists
The wording should be simple and exact, Boorman went on, and use the familiar language of the profession. Even the look of the checklist matters. Ideally, it should fit on one page. It should be free of clutter and unnecessary colors. It should use both uppercase and lowercase text for ease of reading. (He went so far as to recommend using a sans serif type like Helvetica.) (Location 1540)
It is common to misconceive how checklists function in complex lines of work. They are not comprehensive how-to guides, whether for building a skyscraper or getting a plane out of trouble. They are quick and simple tools aimed to buttress the skills of expert professionals. (Location 1602)
Tags: checklists
Who, for example, was supposed to bring things to a halt and kick off the checklist? We’d been vague about that, but it proved no small decision. (Location 1697)
Note: Roles in checklists are very important
idea. In aviation, there is a reason the “pilot not flying” starts the checklist, someone pointed out. (Location 1699)
Moreover, dispersing the responsibility sends the message that everyone—not just the captain—is responsible for the overall well-being of the flight and should have the power to question the process. (Location 1700)
Tags: management, teamwork, responsibility
Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is. (Location 1985)
Note: Checklists are about embracing a culture of teamwork and disciple
“You go into greed mode,” he said. Guy Spier called it “cocaine brain.” Neuroscientists have found that the prospect of making money stimulates the same primitive reward circuits in the brain that cocaine does. And that, Pabrai said, is when serious investors like himself try to become systematic. They focus on dispassionate analysis, on avoiding both irrational exuberance and panic. They pore over the company’s financial reports, investigate its liabilities and risks, examine its management team’s track record, weigh its competitors, consider the future of the market it is in—trying to gauge both the magnitude of opportunity and the margin of safety. (Location 2022)
Tags: money
sure to wash their hands or to talk to everyone on the team”—he’d seen the surgery checklist—“they improve their outcomes with no increase in skill. That’s what we are doing when we use the checklist.” (Location 2087)
Tags: checklists, favorite
You would think that this would be whether the entrepreneur’s idea is actually a good one. But finding a good idea is apparently not all that hard. Finding an entrepreneur who can execute a good idea is a different matter entirely. (Location 2125)
Tags: execution
One needs a person who can take an idea from proposal to reality, work the long hours, build a team, handle the pressures and setbacks, manage technical and people problems alike, and stick with the effort for years on end without getting distracted or going insane. Such people are rare and extremely hard to spot. Smart identified (Location 2126)
Tags: execution
The fear people have about the idea of adherence to protocol is rigidity. They imagine mindless automatons, heads down in a checklist, incapable of looking out their windshield and coping with the real world in front of them. But what you find, when a checklist is well made, is exactly the opposite. The checklist gets the dumb stuff out of the way, the routines your brain shouldn’t have to occupy itself with (Are the elevator controls set? Did the patient get her antibiotics on time? Did the managers sell all their shares? Is everyone on the same page here?), and lets it rise above to focus on the hard stuff (Where should we land?). (Location 2204)