Integrated Preface A List Revolution in Defense of Safety and Correctness Atu?6?1 Gwendolyn has thought y about the problems and challenges facing modern medicine. It is from medicine that The List Revolution also begins, recounting many of the author's experiences as a medical practitioner, but we soon realize that the theme of the book is relevant to virtually all aspects of the modern world, namely, how we cope with the increasing complexity of our work. The complexity of the modern world is beyond human control, and any field that requires practitioners to control a great deal of knowledge is hard to escape. From healthcare to finance, business to administration, life's mistakes are repeated and alarming. According to Gwendolyn, human errors fall into two main categories: "errors of ignorance" and "errors of incompetence". The "errors of ignorance" are mistakes made because we don't have the right knowledge, and the "errors of incompetence" are mistakes made because we have the right knowledge but don't use it correctly. In the book, Gwendolyn gives us many examples of medical cases, from which we can learn that surgical routines are so complex that it is inevitable for healthcare professionals to make mistakes of one kind or another. In a stressful environment, even the best doctor can miss a step or ask a key question that could lead to a mistake during the procedure. Gwendolen also visited pilots and construction crews building skyscrapers and found ways to cope with complex problems from them. Even super-experts need a checklist of key steps that need to be written down on small cards to help them get the job done. In the book, Gwendolen also describes how his research team used this idea to develop the Surgical Safety Checklist. The checklist is now in use around the world with extraordinary results. "Ignorance can be forgiven, but incompetence is not. If the best way to solve a particular type of problem has not yet been found, then we can accept whatever the outcome is, as long as people are doing their best. However, if people know what to do, but fail to do it, it is hard not to be outraged by such mistakes. We are not ignorant, but no matter how careful we are in dividing up our expertise, no matter how great the amount of training we receive, some critical steps will still be overlooked and some mistakes will still be unavoidable. A checklist reminds us not to forget some of the necessary steps and allows the operator to understand what to do. This is not only a method of checking, but also a discipline that guarantees a high level of performance. Checklists provide us with a kind of cognitive protection net that catches the cognitive deficits that everyone is born with, such as incomplete memory or poor concentration. Serious problems can be detected and avoided if the right experts are brought together and allowed to discuss them fully as a team, rather than as individuals. One person is inevitably going to make mistakes, but the likelihood of many people making mistakes may become less. They know that they cannot do it alone, but have to rely on collective wisdom. They use one set of checklists to make sure that no simple problem is missed and no simple step is skipped, and another set of checklists to make sure that all the experts are fully discussing the difficult and unexpected problems and ****ing together to negotiate solutions. What the executives need to do is not to make decisions directly, but to urge everyone to participate actively in the discussion and let them take their share of the responsibility. This is the key to making the list work. The top brass should delegate as much authority as possible to frontline responders and local officials, rather than centralizing power in their own hands. Extremely complex problems are inherently unexpected; it is one of their essential attributes. The traditional paradigm of centralized handling of such problems does not work. An even greater resistance to effective teamwork comes from the negative attitude of "not caring". The fine-grained division of labor allows team members to focus on what they're doing, while ignoring the problems of other team members. This is the situation we face at the beginning of the 21st century: we have accumulated a staggering amount of knowledge. This knowledge is held by some of the most highly trained, skilled, and hard-working people in human society. And, indeed, they have used this knowledge to achieve extraordinary results. But it is not easy to use this complex knowledge appropriately. In every field, from medicine to finance, from business to administration, avoidable mistakes and failures abound, frustrating and demoralizing practitioners. And the reason for this predicament is becoming increasingly obvious: the amount and complexity of the knowledge we possess has outstripped the scope of an individual's ability to perform it correctly, safely and reliably. Knowledge has indeed saved us, but it has also overwhelmed us. We need a great transformation to prevent mistakes and failures, one that is grounded in what has already been learned, that makes the best use of the knowledge we have, and that compensates for the inevitable flaws and shortcomings of the human condition.