I have written here and other places on Amy Edmondson's wonderful research on how, when nurses feel as if they have psychological safety, they openly talk about and try to correct drug treatment errors, but when they work in a climate of fear, they are afraid to even admit when they have made mistakes -- which led to a rather bizarre finding in Amy's early research that in nursing units where people felt safe, even compelled,to talk about and learn from mistakes, they reported ten times more errors than in a nursing unit where the supervisor slammed nurses who admitted or where "caught" making mistakes.
This morning's San Francisco Chronicle reports an equally fascinating study on reducing drug treatment errors. This one focuses on the evils of interruptions, which as research by Gloria Mark shows, slows and undermines performance, and creates great job stress. As the article reports "A UCSF program to improve accuracy in administering drugs - with particular emphasis on reducing interruptions that often lead to mistakes - resulted in a nearly 88 percent drop in errors over 36 months at the nine Bay Area hospitals, according to results being released today." The cool thing about the article is that the nurses at different hospitals invented different local methods for reducing interruptions, to the vest you see pictured above to covering windows so colleagues couldn't see them (and thus run in and interrupt them), to developing quiet zones, or quiet times during drug administration. Note that drug treatment errors are huge problem, resulting in over 400,000 preventable injuries per year and 3.5 billion in costs. So a 88% reduction is huge.
This research is also fascinating to me because it shows how, so often, when people say they are too busy, don't have enough money, or their will be resistance to change that these are excuses, or worse yet, negative self-fulfilling prophecies. In particular, I think that people -- especially managers -- often use spending money as a substitute for thinking, when inexpensive and low-tech solutions work just fine. I am looking forward to digging into this research further.