…is the illusion that it has taken place .
When C needs to go into the hospital, we go through a detailed process for ensuring the care team knows everything they need to be able to care for him effectively. The process of getting him checked in takes hours during which time someone writes down all the key information and enters it into a care plan.
We’ve done this a number of times and each time, it eventually becomes clear to us that the key messages were not getting to the nurses that actually cared for C.
For instance, the hardest time to take care of C is when he is having an episode of acid reflux. When this happens his mouth and airways start to overflow with mucus and saliva that needs to be suctioned out and it takes a while to get things under control. Through our experience, we have come up with a series of steps to follow to get things back under control.
We initially thought the problem might be that the nurses didn’t really have time to read through C’s full history in the care plan. There didn’t seem to be any way to highlight the key information. So we even tried posting key information at C’s bedside. But it didn’t work. When faced with
It seems like as we add more pieces of new information, it becomes exponentially more likely that something will get missed. But what is the limit?
Experiment Idea: Come up with a way to measure how the likelihood of errors goes up as the number/complexity of new ideas goes up. And build on these findings to see if we can find better ways to communicate key ideas to nurses.
Imagine giving participants building blocks and instructions for how to build an object. They are asked to build 4 of these objects in parallel (like caring for 4 patients in the same room). 1 or 2 of the objects have a number of additional instructions that can vary in complexity. Measure the number of errors.