《《the_ergonomics_of_innovation》.pdf

Organization/Strategy By Invitation: The ergonomics of innovation 131 Insights and opinion from outside contributors The ergonomics of innovation A successful campaign to save 100,000 lives shows that efforts to make it easier for organizations to innovate can yield remarkable results. Hayagreeva Rao and Robert Sutton Josie King’s senseless death started with a hot bath. The one-and-a-half- year-old girl climbed into a tub and burned herself in January 2001. Her initial recovery at a large hospital seemed promising, but then the toddler began experiencing insatiable thirst. Nurses told her mother not to let her drink and said that her vital signs were normal, even as she sucked washcloths to quench her thirst. Then, despite a no-narcotics order, a nurse gave Josie methadone, which led to cardiac arrest. Two days later, she died in the intensive-care unit. Josie’s mother, Sorrel, told this heartbreaking story in December 2004 at an event kicking off a campaign to reduce by 100,000 the number of patients who die each year in 1 US hospitals because of preventable errors. A small nonprofit called the Institute for Healthcare Improvement (IHI) was behind the 100,000 Lives campaign. By June 2006, the hospitals enrolled in it had accomplished this goal.2 Although the organization lacked formal author- 1The target of 100,000 represented about half of the number of people who died in US hospitals from 2000 to L i z 2002 because of preventable errors. See “Patient safety in American hospitals,