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The Checklist Manifesto
How To Get Everything Right
First checklist was developed for the Boeing Flying Fortress, the first 4 engined bomber. Crashed on an early test flight, killing most of the crew, because the highly experienced pilot, trying to adjust controls as taking off, forgot to release the rudder control lock. Planes had simply become so complex that no matter how capable you were, you couldn't remember everything needed to do.
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In old days, a cathedral built by a master builder who oversaw the construction from start to finish. Then gradually tasks fragmented until today a wide range of specialist crafts.
Medicine is still stuck in the master craftsman stage. Most systems run as if still controlled by one guy at the top who is in charge of the whole process. But reality is that it is highly fragmented set of doctors, nurses, support and admin, basically unco-ordinated and so lots of overlap, duplication and cracks for people to fall through,
Today, in the construction business, no room for error. If a building doesn't go up when you say it will, and perform as to specs, you'll get sued. And to achieve that, you start with a checklist. An individual one for each building. In the case of a skyscraper, reps of all the trades sit down at table and figure out all the steps. The overall manager had a scheduled series of meetings where each subgroup manager reviewed the progress of each stage, and discussed any problems.
The wisdom of the group exceeds the wisdom of a single expert. man is fallible, but men are less so. Specific software called Clash Detective, which highlights conflicts and building code problems.
Van Halen's notorious demand for a bowl of M & M's with all brown candies removed - a ruse rather than a power-mad celebrity tantrum. Their concert performances needed a telephone book of specs to make sure everything worked, and on schedule. They had 9 eighteen-wheelers full of equipment, so details had to be precisely followed. The brown candy was a simple test - if they found them, it meant someone wasn't on the job, so they would go through the spec sheet with a fine comb, and inevitably find where another corner had been cut.
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Volume of surgery has grown so rapidly that exceeds global totals for childbirth - but with a death rate 10 - 100 times higher. Worldwide, at least 7 million people a year are left disabled, and a million ide - a level of harm that approaches that of malaria or Tb.
When operating, need to give antibiotics within 1 hour before making first incision. Children's hospital records showed that a third were not getting antibiotics within that window. Some got it too soon, some too late, some not at all. So put up a checklist. To make sure it was followed, head nurse taught to put a metal 'tent' over scalpels when setting up instruments, and only remove it when checklist had been gone through. Within months they got 100% compliance.
Surgery has 4 big killers: infection, bleeding, anesthetics error, and 'the unexpected'. Found the most effective way to deal with the last item was for whole team to have a preparatory chat through the case together - to consider as a team any potential problems that could apply to that particular patient.
See also The Hair of the Dog
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