One of the things Gawande learned about the construction industry is the way it decentralizes decision-making. He examines the American government’s response to Hurricane Katrina in 2005 and suggests that many of the failures of this response stemmed from a failed model of top-down command. He then points to Wal-Mart’s response, which delegated authority to individual store managers. This proved a more effective response than that of the federal government. Because communication was a problem during Hurricane Katrina, top-down command structure proved inadequate. With the freedom to follow their instincts, Wal-Mart’s store leaders illustrated the importance of adaptability in complex situations. Wal-Mart was able to provide immediate relief to first-responders in a way that the federal and state governments could not.

Gawande discusses how seemingly everywhere he looked, checklists were the norm. He mentions the infamous “Brown M&M” incident made famous by musician David Lee Roth of the rock band Van Halen. Roth included an odd request (the removal of brown M&Ms from a bowl of M&Ms) as a means of ensuring the checklist for Van Halen performances was followed. If he discovered brown M&Ms, he knew the checklist was not followed. Because of the magnitude of Van Halen shows, one misstep could lead to injury.