The Recommendation That Reached Two People Out of Six

Cover of Before Harm Happens

A speech-language pathologist finishes a bedside swallow assessment and writes a clear recommendation: this patient takes thickened liquids only, and nothing by mouth without supervision. The assessment was expert, the recommendation is correct, and it is about to fail, not because anyone disagrees with it, but because of how many people need it and how … Read more

What the Pharmacy Override Log Is Trying to Tell You

Cover of Before Harm Happens

Every automated dispensing cabinet keeps a log of its overrides, the times a nurse pulled a medication before a pharmacist reviewed the order. In the imagined version of the process, this pathway is rare, urgent, and justified, an emergency valve for the moments when waiting for review would itself be dangerous. Then you open the … Read more

The Risk Doesn’t Live in the Room. It Lives in the Hallway.

Cover of Before Harm Happens

Hospital process maps tend to go blank in the same places: the corridor, the elevator, the twenty minutes a patient spends between one department’s care and another’s. These are treated as connective tissue, mere transport between the parts of the map where the real work happens. They are, in fact, where a surprising share of … Read more

The Most Important Voice in the Room Is Often the Quietest

Cover of Before Harm Happens

The senior physician says, with complete confidence, that this step never fails. Across the table, the pharmacy technician who watches it fail most Tuesdays looks down and says nothing. In that small moment of silence a risk analysis can quietly die, and produce something worse than nothing on its way out: false reassurance, stamped and … Read more

The Thirty-Minute Risk Analysis You Can Run Tomorrow

Cover of Before Harm Happens

There is a myth that proactive risk work requires a chartered project: a sponsor, a trained facilitator, eight weeks, a wall covered in sticky notes. For a high-stakes process, all of that is appropriate. For the hundred smaller moments where a little foresight would help, it is so disproportionate that the analysis simply never happens, … Read more

An FMEA Is Finished When the Fix Is Boring

Cover of Before Harm Happens

Two years after a genuinely good analysis, walk back to the process it fixed and you will often find the fix gone. Not rejected, not overturned in any meeting anyone remembers. Simply evaporated. A staffing change reassigned the person who did the extra check. A software update quietly dropped the alert. The workaround crept back … Read more

The Fix That Feels Productive and Changes Nothing

Cover of Before Harm Happens

Watch what happens at the end of most risk analyses. The hard work is done, the hazards are named and ranked, and then, in the last forty-five minutes, the team disposes of them. The disposal, with dispiriting regularity, reads the same way. Re-educate the staff. Revise the policy. Remind everyone at the huddle. Add it … Read more

Stop Arguing About Whether It’s a Six or a Seven

Cover of Before Harm Happens

Somewhere right now a capable team is spending forty minutes deciding whether a risk scores a six or a seven. They will not resolve it, because there is nothing to resolve. The distinction does not exist outside the worksheet, and while they argue it, the hazard they agree is serious sits unaddressed. This is scoring … Read more