A Boeing B-17 Flying Fortress, known at the time as the model 299, sits on the tarmac in 1935. This revolutionary aircraft—bigger, more complex, and more powerful than anything before it—takes off for its demonstration flight and climbs to 300 ft before stalling and crashing back to the earth, killing 2 of the 5 crew members on board including the pilot. The cause? Not mechanical failure, but human error. The experienced test pilot forgot to release a critical control lock, a simple oversight that led to tragedy.
After the tragedy, Boeing lost the military contract despite their model plane being capable of flying faster, farther, and carrying more than its competitors. This sophisticated plane was deemed by critics “too complex to fly”.
Boeing remained convinced that this plane was not too complex to fly but was merely “too complicated to be left to a pilots memory”. This incident gave birth to one of the most transformative safety tools in history: the aviation checklist. Follow the creation of their aviation checklist Boeing went on to successfully fly the model 299 1.8 million without a single incident. Leading to the army eventually agreeing to purchase 13,000. And the B-17 became a transformative force in WW2 giving the allies an advantage in the air and carrying out devastating bombing campaigns against the nazi forces. (For the full story)
Today, as paramedics facing increasingly complex medical protocols and life-saving interventions expected to be performed in time sensitive, dynamic and high risk environments, we can learn invaluable lessons from aviation’s journey toward systematic safety.
Why Checklists Matter More Than Ever in EMS
As Atul Gawande notes in “The Checklist Manifesto,” much of our work today has entered its own “B-17 phase”—becoming too complex for any one person to manage reliably from memory alone. In emergency medicine, we encounter thousands of possible presentations, drug interactions, and procedural variations. A Pennsylvania trauma study found 1,224 different injury-related diagnoses presenting in over 32,000 unique combinations. That’s equivalent to having 32,000 different types of aircraft to know how to safely operate.
The stakes in our field mirror those in aviation: when things go wrong, lives are lost. But here’s the encouraging truth—just as aviation transformed from a high-risk career to one of the safest industries in the modern decade through systematic approaches like checklists, emergency medicine can achieve similar gains.
Aviation’s Hard-Learned Lessons
The aviation industry didn’t embrace checklists overnight. Multiple crashes in the late 1980s, including Northwest Airlines Flight 255 and Delta Flight 1141, were directly attributed to checklist misuse or omission. These tragedies sparked intensive research into what makes checklists effective versus mere procedural theater.
NASA’s research revealed that poorly designed checklists can actually become “resident pathogens” in the system—tools that appear helpful but contribute to failure. The key insight: checklists must be human-centered, accounting for how people actually behave under stress, not how we wish they would behave.
Core Principles for Effective Medical Checklists
1. Simplicity and Brevity
The original B-17 checklist fit on an index card. Aviation research consistently shows that lengthy checklists get skipped or partially completed. For paramedics, this means focusing on critical, easily-forgotten items rather than comprehensive protocols.
Example: Instead of a 20-item cardiac arrest checklist, focus on the 6-8 critical items most likely to be overlooked under stress
2. Strategic Timing and Triggers
Aviation checklists are triggered by specific phases of flight—takeoff, landing, emergencies. Similarly, medical checklists should align with natural workflow breaks and decision points.
3. Stress-Adapted Design
Under stress, humans experience tunnel vision, memory impairment, and reduced cognitive flexibility. Aviation research shows that emergency checklists must account for these limitations through:
- Large, clear typography that remains readable in poor lighting
- Logical grouping of related items
- Explicit action words (“Check,” “Verify,” “Confirm”)
- Failure modes clearly addressed
4. Focus on Critical Items
Not everything needs to be on a checklist. Aviation distinguishes between “nice to have” and “critical to safety.” The best medical checklists focus on:
- High-risk, low-frequency procedures
- Steps with serious consequences if omitted
- Items frequently forgotten under stress
- Communication and handoff points
Checklist Types for Different EMS Scenarios
Normal Checklists
For routine procedures like medication preparation or equipment checks. These should be brief, memorable, and easily integrated into normal workflow.
Emergency Checklists
For high-acuity situations requiring immediate action. Design principles:
- Immediate actions listed first
- Time-critical steps clearly marked
- Decision points explicitly noted
- Clear stopping points when specialist help is needed
Communication Checklists
For handoffs between providers, hospital communication, and team coordination. These prevent critical information loss during transitions of care.
Implementation: Learning from Aviation’s Mistakes
Aviation’s checklist evolution teaches us several implementation principles:
Human-Centered Design
Checklists must accommodate real human behavior, not idealized behavior. If your team consistently skips certain items, the checklist design is the problem, not the team.
Cultural Integration
In aviation, checklist use is deeply embedded in professional culture. For EMS adoption, this means:
- Leadership modeling proper use
- Training that emphasizes why, not just how
- Regular review and refinement based on user feedback
- Recognition that resistance often indicates design flaws
Avoid the “Compliance Trap”
Simply mandating checklist use doesn’t improve outcomes. Focus on making checklists genuinely helpful tools that teams want to use because they improve performance and reduce stress.
Overcoming Common Objections
“Every patient is different”
True, but certain critical safety steps remain constant. Checklists don’t replace clinical judgment—they free up mental capacity for the complex decision-making that makes us valuable.
“We don’t have time”
A well-designed checklist saves time by preventing errors, reducing rework, and streamlining communication. Aviation crews manage complex emergency checklists in seconds because they’re properly designed and practiced.
“I know what I’m doing”
So did the experienced pilots who crashed because of simple oversights. Expertise doesn’t eliminate human fallibility—it makes systematic approaches even more important.
The Bottom Line
Aviation transformed from a dangerous endeavor to the safest form of transportation through systematic approaches to human error. The checklist was central to this transformation, not because it eliminated the need for skill and judgment, but because it freed professionals to apply their expertise where it matters most.
As paramedics, we face similar complexity and similar stakes. The question isn’t whether we’re capable professionals—we are. The question is whether we’re willing to adopt proven tools that help capable professionals perform even better when it matters most.
The patients we serve deserve nothing less than our best systematic approach to safety and care. Aviation showed us the way—now it’s time to follow their lead.
What checklist challenges have you encountered in your EMS practice? Share your experiences and ideas with your colleagues—the best safety improvements often come from frontline insights.