The Moment You Can’t Ignore

University Hospital

When a patient at University Hospital (UH) was suffering from severe abdominal pain, Dr. Piersen, the hospital’s leading surgeon, performed surgery that lasted nearly eight hours. As he was about to close the incision, Marco Fierro, the scrub tech, told him that a sponge was missing. Piersen ignored Fierro, and the two almost came to blows. A nurse restored calm, they found the missing sponge and the patient made a full recovery.

While the patient escaped harm, the volatile situation in the surgery theater raised a red flag with hospital management. Dr. Davidian, head of the medical staff and procedures, launched an investigation. A relatively new program, Putting Patients First (PPF), had thrown the hospital into turmoil. The program synthesized internal safety protocols with requirements from outside institutions such as the World Health Organization. PPF put the responsibility for patient safety into the hands of hospital employees, from scrub techs to surgeons. The new processes, checklists and protocols forced UH staffers to adopt new ways of working, whether they wanted to or not.

Dr. Piersen believed in an orderly chain of command in...