[183] the hospital was fined another $450,000 Felice Freyer, “Another Wrong- Site Surgery at R.I. Hospital,” The Providence Journal, October 28, 2009; “Investigators Probing 5th Wrong-Site Surgery at Rhode Island Hospital Since 2007,” Associated Press, October 23, 2009; “R.I. Hospital Fined $150,000 in 5th Wrong-Site Surgery Since 2007, Video Cameras to Be Installed,” Associated Press, November 2, 2009; Letter to Rhode Island Hospital from Rhode Island Department of Health, November 2, 2009; Letter to Rhode Island Hospital from Rhode Island Department of Health, October 26, 2010; Letter to Rhode Island Hospital from Centers for Medicare and Medicaid Services, October 25, 2010.
[184] “The problem’s not going away,” “ ‘The Problem’s Not Going Away’: Mistakes Lead to Wrong-Side Brain Surgeries at R.I. Hospital,” Associated Press, December 15, 2007.
[185] “everything was out of control.” In a statement, a Rhode Island Hospital spokeswoman wrote: “I never heard of any reporter ‘ambushing’ a doctor-and never saw any such incident on any of the news stations. While I can’t comment on individual perceptions, the quote implies a media frenzy, which did not happen. While the incidents received national attention, none of the national media came to Rhode Island.”
[186] a sense of crisis emerged In a statement, a Rhode Island Hospital spokeswoman wrote: “I would not describe the atmosphere as being one of crisis-it was more accurately one of demoralization among many. Many people felt beleaguered.”
[187] to make sure time-outs occurred The cameras were installed as part of a consent order with the state’s department of health.
[188] A computerized system Rhode Island Hospital Surgical Safety Backgrounder, provided by hospital administrators. More information on Rhode Island Hospital’s safety initiatives is available at http://rhodeislandhospital.org.
[189] But once a sense of crisis gripped For more on how crises can create an atmosphere where change is possible in medicine, and how wrong-site surgeries occur, see Douglas McCarthy and David Blumenthal, “Stories from the Sharp End: Case Studies in Safety Improvement,” Milbank Quarterly 84 (2006): 165-200; J. W. Senders et al., “The Egocentric Surgeon or the Roots of Wrong Side Surgery,” Quality and Safety in Health Care 17 (2008): 396-400; Mary R. Kwaan et al., “Incidence, Patterns, and Prevention of Wrong-Site Surgery,” Archives of Surgery 141, no. 4 (April 2006): 353-57.
[190] Other hospitals have made similar For a discussion on this topic, see McCarthy and Blumenthal, “Stories from the Sharp End”; Atul Gawande, Better: A Surgeon’s Notes on Performance (New York: Metropolitan Books, 2008); Atul Gawande, The Checklist Manifesto: How to Get Things Right (New York: Metropolitan Books, 2009).
[191] In the wake of that tragedy NASA, “Report to the President: Actions to Implement the Recommendations of the Presidential Commission on the Space Shuttle Challenger Accident,” July 14, 1986; Matthew W. Seeger, “The Challenger Tragedy and Search for Legitimacy,” Communication Studies 37, no. 3 (1986): 147-57; John Noble Wilford, “New NASA System Aims to Encourage Blowing the Whistle,” The New York Times, June 5, 1987; Joseph Lorenzo Hall, “Columbia and Challenger: Organizational Failure at NASA,” Space Policy 19, no. 4 (November 2003), 239-47; Barbara Romzek and Melvin Dubnick, “Accountability in the Public Sector: Lessons from the Challenger Tragedy,” Public Administration Review 47, no. 3 (May-June 1987): 227-38.
[192] Then, a runway error Karl E. Weick, “The Vulnerable System: An Analysis of the Tenerife Air Disaster,” Journal of Management 16, no. 3 (1990): 571-93; William Evan and Mark Manion, Minding the Machines: Preventing Technological Disasters (Upper Saddle River, N.J.: Prentice Hall Professional, 2002); Raimo P. Hamalainen and Esa Saarinen, Systems Intelligence: Discovering a Hidden Competence in Human Action and Organizational Life (Helsinki: Helsinki University of Technology, 2004).
[193] grab an extra box The details on subconscious tactics retailers use comes from Jeremy Caplan, “Supermarket Science,” Time, May 24, 2007; Paco Underhill, Why We Buy: The Science of Shopping (New York: Simon and Schuster, 2000); Jack Hitt; “The Theory of Supermarkets,” The New York Times, March 10, 1996; “The Science of Shopping: The Way the Brain Buys,” The Economist, December 20, 2008; “Understanding the Science of Shopping,” Talk of the Nation, National Public Radio, December 12, 2008; Malcolm Gladwell, “The Science of Shopping,” The New Yorker, November 4, 1996.
[194] to buy almost anything There are literally thousands of studies that have scrutinized how habits influence consumer behaviors-and how unconscious and semi-conscious urges influence decisions that might otherwise seem immune from habitual triggers. For more on these fascinating topics, see H. Aarts, A. van Knippenberg, and B. Verplanken, “Habit and Information Use in Travel Mode Choices,” Acta Psychologica 96, nos. 1-2 (1997): 1-14; J. A. Bargh, “The Four Horsemen of Automaticity: Awareness, Efficiency, Intention, and Control in Social Cognition,” in Handbook of Social Cognition, ed. R. S. Wyer, Jr., and T. K. Srull (Hillsdale, N.J.: Lawrence Erlbaum Associates, 1994); D. Bell, T. Ho, and C. Tang, “Determining Where to Shop: Fixed and Variable Costs of Shopping,” Journal of Marketing Research 35, no. 3 (1998): 352-69; T. Betsch, S. Haberstroh, B. Molter, A. Glockner, “Oops, I Did It Again-Relapse Errors in Routinized Decision Making,” Organizational Behavior and Human Decision Processes 93, no. 1 (2004): 62-74; M. Cunha, C. Janiszewski, Jr., and J. Laran, “Protection of Prior Learning in Complex Consumer Learning Environments,” Journal of Consumer Research 34, no. 6 (2008): 850-64; H. Aarts, U. Danner, and N. de Vries, “Habit Formation and Multiple Means to Goal Attainment: Repeated Retrieval of Target Means Causes Inhibited Access to Competitors,” Personality and Social Psychology Bulletin 33, no. 10 (2007): 1367-79; E. Ferguson and P. Bibby, “Predicting Future Blood Donor Returns: Past Behavior, Intentions, and Observer Effects,” Health Psychology 21, no. 5 (2002): 513-18; Edward Fox and John Semple, “Understanding ‘Cherry Pickers’: How Retail Customers Split Their Shopping Baskets,” unpublished manuscript, Southern Methodist University, 2002; S. Gopinath, R. Blattberg, and E. Malthouse, “Are Revived Customers as Good as New?” unpublished manuscript, Northwestern University,
