Switch - Chip Heath [77]
The nurses understand what’s expected of them—the critical moves are clear—so this isn’t a Rider problem. Nor do the nurses have any emotional resistance to better focus. In fact, it annoys them when they’re distracted by others, which means that, in this case, we have the luxury of a supportive Elephant. The problem, it seems, is the distractions themselves. No one thinks twice before calling out to a nurse who’s walking the halls delivering medication. Worse, nurses feel an obligation to respond when others distract them. No one wants to tell a surgeon, “Sorry, bub, can’t help right now. I’m dealing with medication.” Yet that’s exactly what needs to happen if errors are to be reduced.
What Richards needed to do was make other people aware that they were interrupting the nurses. She needed to make the bad behavior visible. Ideally, when the nurses were administering medication, they would work inside a soundproof bubble, like the “Cone of Silence” from Get Smart. With that solution being architecturally infeasible, Richards came up with the idea of using a visual symbol, something that could be worn by nurses, that would signal to other people, Hey, don’t bother me right now. I’m passing out medication.
After considering armbands and aprons, Richards settled on vests and decided to call them “medication vests.” Where do you buy a medication vest? Richards had to make do with what she could find: “The first vest we ordered was off the internet. It was really cheesy. Cheap plastic. Bright orange. Be careful what you order off the internet.”
Later, with vests in hand, Richards unveiled the idea to her staff: When you’re administering medication, you’ll put on a medication vest. It’s bright enough that people can see it from down the hall. And all of us, including the doctors, will know that when someone is wearing one of these vests, we should leave that person alone.
She selected two units at Kaiser South for a six-month pilot study of the medication vests, and in July 2006 it began.
Richards quickly encountered a problem. The nurses hated the vests. So did the doctors. “Nurses thought the vest was demeaning, and they couldn’t find it when they needed it,” said Richards. “They didn’t like the color. They’d ask, ‘How do you clean it?’ And physicians hated not being able to talk to their nurses when they passed them in the hall.”
The nurses’ written feedback was scathing: “Oh, so you want to draw attention to the fact we can make a mistake.” “You want people to think I have a dunce cap on, that I’m so stupid I can’t think on my feet.” “Give me a hard hat and a cone and I can go work for Caltrans [the state highway department].”
“They were pretty brutal,” said Richards. The reception was so universally poor that Richards was ready to write off the idea and try something else.
Then the data came back.
During the six-month trial period, errors dropped 47 percent from the six months prior to the study. “It took our breath away,” said Richards.
Once the data were in, the hatred faded. Impressed by the results, the entire hospital adopted the medication vests, except for one unit that insisted they weren’t needed. Errors dropped by 20 percent in the first month of the hospitalwide adoption, except in one unit, which actually saw an increase in errors. (Guess which one.)
You know you’ve got a smart solution when everyone hates it and it still works—and in fact works so well that people’s hate turns to enthusiasm. Becky Richards had found a way to change the Path.
5.
The airline industry has long used a consistent practice. Because most aircraft accidents happen during takeoffs and landings—the most hectic and coordination-intensive parts of any flight—the industry adopted the “sterile cockpit” rule. Anytime a plane is below 10,000 feet—whether on the way up or the way down—no conversation is permitted in the cockpit, except what’s directly relevant for flying. At 11,000 feet, members of the cockpit