“Start the Clock” was coined in 2006 during our early work at Sentara Healthcare. A high-risk deficiency in medication labeling of dispensed syringes was identified at Sentara Leigh Hospital. The presenting scenario was this. A physician ordered 12mg Metoprolol. Upon vending, the medication dispensing system instructed the nurse to take one syringe. The label on the syringe read as follows:
 
The label indicated the concentration only while the 5ml syringe, in fact, contained the full dose of 12mg Metoprolol – all was good. Yet the nurse interpreted the concentration on the label as the total dose in the syringe. (As a contributing factor in this scenario, the label was covering the measurement gradient on the syringe.) The nurse thought, “Hmmm, that would mean that I would need to administer FIVE syringes to get the total dose.” And as if to confirm, there just happened to be four additional syringes lying in the bin of the med dispensing system! Yet putting good critical thinking to work, the nurse then considered, “It seems odd to have to administer five of anything – I should check this out.” The nurse sought verification, the confusion about the dose in the syringe was resolved, and the correct dose administered.

 
What seems as Safety Success Story ready for distribution doesn’t end there. Sentara’s Medication Safety Officer recognized, “Ah, this labeling practice of ours is a hole in the Swiss cheese just floating around, waiting to combine with a human error in dose interpretation and lead to an event of harm. We need to close that hole…and quickly.” Start the Clock was born. In 17 hours, Sentara modified their syringe labeling practice – across the system – to include total dose in addition to concentration, closing the hole in the Swiss cheese.

A growing number of healthcare organizations across the United States have adopted Start the Clock as a high-reliability leadership method for communicating a shared sense of urgency to resolve safety-critical issues. The variant “Clock Tickers” was first coined by Asante Health’s Rogue Valley Medical Center as a title for their tracker of those issues.

Questions to Consider

1. When it comes to system issues identified in your organization, how do you differentiate issue severity?
2. For the most significant issues, does your leadership and culture promote a shared sense of urgency-to-solve?
3. As a real-time metric of safety, do you track time-to-resolution of your Start the Clock safety critical issues?
    
   And one more question for good measure…
4. This story is a great example of an organization that goes beyond problem-solving to cause-solving. When Safety Success Stories present in your organization, do leaders consider underlying causes and extent-of-condition of safety critical issues?