Atul Gawande watched surgeons at Johns Hopkins miss tiny steps before an operation.
Not because they lacked skill. Because a busy OR makes simple things disappear.
In The Checklist Manifesto, he argues that expertise fails at the edges: handwashing, instrument counts, a pause before the first incision.
The fix is almost embarrassingly plain. A short checklist gives the team one shared memory when adrenaline starts to blur the room.