Medication Errors Example

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Adapted from Creativity, Innovation, and Quality by Paul E. Plsek (1997: Quality Press).
© 1997 Paul E. Plsek. All rights reserved.
For information on purchasing this book, visit The Creativity Bookstore.

An Example of Directed Creativity: The Hospital Medication Errors Quality Improvement Team

The Problem

To illustrate what we mean by directed creativity, consider the case of the hospital medication process quality improvement (QI) team that I once worked with. This medication QI team was a model of the scientific approach to quality improvement. They had gathered data on the problem, identified the key types of medication errors, constructed cause-effect diagrams and flowcharts, collected more data, identified root causes, implemented remedial process changes, and measured improvement. The team members were successful with every medication error-type they focused on except one: medications not administered on time ("late meds").

Interviews with the nurses indicated that the primary cause for late meds was simply that the nurses got busy and forgot to give the medications at the prescribed times. As a solution, the team had posted a log sheet at the nurses' station with all of the patients' medication times written in chronological order as a reminder. But, as it turned out, the nurses were too busy to look at the log sheet! Unable to secure the resources to relieve the workload burden on the nurses, the team was frustrated and had decided to accept the remaining error-rate as simply inevitable.

Here is a team stuck in its thinking. The team had gone down a logical path in its analysis and had come up with a logical solution. The solution should have worked, but it didn't. Team members had put so much analytical effort and logical thought into the work that led up to this point, that they were unable to think of anything else to do. Whenever they discussed the matter, they just kept coming back to the same stuck point, rejustifying their analysis, and decrying the lack of resources as the real root cause of the problem. "Stuck thinking" is a common occurrence in quality improvement activities in business. Directed creativity can be used to relieve stuck thinking.

The Directed Creativity Approach

A directed creativity process for the medication error situation might have proceeded in the following manner:

Realize that analytical thinking has reached a "stuck point," but then resolve to find a creative way beyond it.

The team needed to acknowledge the constraints in the situation, but adopt the attitude that "there has got to be something else we can do."

Clarify the focus or concept that requires new thinking.

In this case: We need a way to remind busy people when a certain time has come.

Review the facts.

We have tried to remind them with a time log, but that failed.

Look carefully at the current situation to identify elements that could be modified to yield a new approach.

We have tried reminding them visually... sight is only one of our senses... hearing, touching, tasting, smelling are others. We have used a paper time log... a large white board or a computer screen is another option.

Restate the focus by modifying an element and looking for an association.

How could I remind a busy person about time through hearing rather than sight? The mental association of the concepts of reminding, time, and hearing leads us naturally to identify an alarm clock as a mechanism. We could go on to think of other ways to utilize other senses, or modify other elements of the situation.

Develop the idea further to meet practical constraints.

For example, it must not cost too much; it must be flexible, portable, easy to associate with individual patients, and so on. One way is to use a stick-on alarm clock; the kind that you can attach to an appliance or car dashboard, they are typically available in the line at the supermarket check-out counter.

Express it, develop it, try it out, see what happens.

The team went out and purchased a few of these stick-on alarm clocks, set them for the appropriate medication times, and stuck them to the appropriate patients' charts. Now, even if the nurses are very busy, when the alarm goes off someone hears it and is reminded that it is time to administer a medication. The implementation of this idea reduced the late-med-rate to nearly zero, without the addition of extra staff.

These processes of directed creativity are based on modern theories of how the mind works. Furthermore, they utilize ordinary thought processes like noticing, associating, remembering, and selecting. No special genius is required. Finally, while the end product of the thinking is creative--a new idea--the thought processes have a logic that makes them appealing even to serious, scientific people (like those who typically work in business).

A Closer Look at the Mental Processes Behind Directed Creativity

While the thinking process outlined above is not a universal sequence that can be applied to all situations, it does illustrate five, basic mental actions that are common to many successful creative thinking endeavors.

Some Basic Mental Actions In Directed Creativity

Clarify the focus with a broad statement
Recognize the concepts in the current situation
List alternatives
Make mental associations
Develop ideas into practical realities

First, it is often necessary to stop and clarify the focus that requires creative thinking. By stating the focus broadly--"I need a way to remind busy people when a certain time has come"--we give our minds both a fixed point from which to direct our thinking, and a wide space in which to come up with alternatives.
Being clear about the current reality and looking carefully to notice the underlying concepts behind the common things around us is a second critical element in directed creative thinking. Often, we fail to pause and consider how or why something works or fails. The medication time log was a good idea, but it failed. If we stop and think about why it failed we might realize that an underlying assumption was that the nurses would find time to look at it. But, what we found was that they were too busy, which, of course, simply brings us back to the original problem. The key insight here is to notice that the failed solution relied on the sense of sight to do the reminding.
Listing alternatives is a third key element in the directed creativity process in this situation. Recognizing that reliance on the sense of sight had failed, directed creativity suggests that we simply list our other senses and consider them as alternative ways of reminding. Careful reflection on this list of senses would lead us to notice that while it is difficult to look at something when you are busy with something else, it is easy to hear something even when you are otherwise occupied. This is not an earth-shaking insight. So, why didn't the team members think of it? I believe it is because our minds tend to race quickly past it on the way to the only approach we can think of; i.e., the way we remind nurses in a hospital is with a log sheet. So, paradoxically, stuck thinking does not necessarily mean that thinking has stopped. A better metaphor is to say that our thoughts are racing toward a repeated collision with the same brick wall! Listing alternatives helps us slow down our thinking, look around, and find an alternative side street to turn down before we hit that same brick wall again.
Fourth, this example also illustrates the fundamental thinking process of "association." When we associate the concepts of reminding, time, and hearing, we come up with the idea of using an alarm clock. Association lies at the core of all creative thought.
Finally, this example illustrates the importance of further refining our ideas in order to make them truly useful. Many good ideas are never implemented because our first impressions of them makes them seem unappealing. Since, by definition, a creative idea is a new idea, we cannot be sure what mental model people will conjure up when we first express it. For example, imagine a row of bedside alarm clocks with big brass bells on top going off at various times. This mental picture would certainly lead to immediate rejection of the alarm clock idea as too goofy. But, rather than prematurely rejecting the idea, we should consider the alarm clock suggestion merely a "seed" of an idea that must be further refined. In the creative development process, we can address practical issues such as cost, fit with the environment, need for flexibility, and so on.

Directed Creativity Versus Stuck Thinking

Directed creativity is needed in business for the simple reason that sometimes creative thinking is useful. When we are "stuck" in our thinking--whether trying to solve a problem, redesign a process, develop a new service, or delight a customer--it may not do any good to simply think harder. If our analytical thinking has locked us in to a particular approach that is unfruitful, thinking harder is analogous to driving faster into the same brick wall in hopes that we will break through it. While there may be a slight chance of success with this brute force approach, wouldn't it be easy to drive around the wall or construct a ramp over it? Driving around or over the walls in our thinking is the creative approach.

Reflecting on the late meds case and other "stuck thinking" situations like it, we can clearly see that there are limits to traditional analytical thinking when it comes to solving nagging problems or generating breakthrough ideas. What we need is the ability to be analytical when the situation calls for it, and creative when the situation calls for that. Both skills are critical for success in business.

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