This is one of a collection of stories that are like “Final Destination” meets “The Monkey’s Paw” (W. W. Jacobs, 1902). As such, they are tragedies more than either mysteries or horror, and would appeal most to readers who enjoy the inexorable pull of a story arc that leads to doom. In each story, a protagonist makes a wish that comes true with fatal results for someone, often the person making the wish. Nothing supernatural, but just how things work out. (Or is it?) The technical details surrounding the fatal (or near-fatal) event are drawn from real cases in the US OSHA incident report database and are therefore entirely realistic even if seemingly outlandish. The plots draw lightly from cultural beliefs around actions such as pointing at someone with a stick or knife, wishing in front of a mirror, or stepping on a crack.


Grace Smithington-Ebenezer hated scratchy pens. They grated on her soul, and made her irritable, but scratchy pens were nothing compared to the incandescent rage she felt when given a badly designed form.

She knew that this might appear petty, but as the nurse executive at a busy city hospital, she also knew that patient flow and experience often faltered on the rocks of a bad intake form. Grace had been inspired by seeing an episode of “Undercover Boss” and now regularly put herself through the patient process at various units, often in disguise.

Today was the turn of orthopedics at a satellite hospital, and already the experience was sour. They opened the doors 2 minutes late, the pen was scratchy, and three of the forms required the exact same information to be filled in. Grace checked herself in her compact mirror to make sure her wig was still on straight and then tried to catch the eye of the unit admissions nurse. After several futile attempts, Grace got up and stood directly in front of the nurse’s station. As a woman of color, she was entirely accustomed to being somewhat invisible, ignored, and at best, vaguely tolerated, and this was her best weapon in her fight against poor quality care. Her disguises were inventive and well executed but were probably unnecessary—once Grace presented in the role of a patient, she became unrecognizable to most staff, and she got a firsthand appreciation of what patients were experiencing.

With one hand in her pocket, Grace triggered a stopwatch, and waited until the nurse finally acknowledged her presence. “Yes?” was all that was forthcoming in the end. Grace clicked the stopwatch again, smiled sweetly, and making a mental note of the noncompliance in standard greeting, she posed a loaded question. “I was jus wondering, how long fo to see the doctor?” A fake tremulous voice to go with a fake uneducated persona. The nurse practically rolled her eyes and gave a non-answer to the effect that it would happen when it happened. Grace had a few more questions, and then went back and made notes of every noncompliance, low-quality interaction, and every bit of smartmouthery.

Grace took off her wig and drab coat, put her name tag back on, and returned to the nurse’s station. In a clear voice that rang with authority, she engaged the nurse again. A confused expression fought briefly and lost to one of dismay, as it dawned on the nurse that she had just smartmouthed the most senior nurse executive in the system and may be unemployed by the end of her shift. However, Grace was not about punishment, and was laser focused on fixing practice instead. Grace ran through the list of things that had not complied with directives and standard operating procedures, giving the nurse specific examples and instructions on correcting the noncompliance.

Her next step was a walkthrough of the patient flow, and then after an inspection of the offices, she explained several safety issues to a chastened head of orthopedics.

Grace prioritized where to visit by looking through unit and departmental quality and performance metrics. She pulled up the top and bottom performers and normally picked one at random. This time, she decided to visit one of the top performers that frankly looked too good to be true. Grace dispensed with the disguise in this case and decided to book an appointment with the head of the department.

Dr. Rebecca Vogel was the head of surgery at one of the 500-bed hospitals in the system and was in the top ten percentile for performance—patients seen, on time starts, financials, etc., but led the system in quality metrics—low medical errors, accidents, high patient reviews, and the like.

Dr. Vogel could explain their success. “Firstly, we don’t beat up on staff or assume they’re lazy or idiots. Secondly, we use the KPIs as a guide, rather than a focus or an objective. We focus on the job of surgery and getting the basics right every time. The KPIs give us a hint as to whether we are on the right path, but they aren’t our focus. Our major focus is on delivering quality care, not on achieving a KPI.”

Grace felt like giving Rebecca a standing ovation but could see there was more. Rebecca glanced out of the window at the mountains and took a deep breath. “Perhaps the biggest thing for us, is that we include the patient as part of our care team.” Rebecca explained how patient health goals were the objective, and patients had a role at every step, from which surgical method to use—open surgery, laparoscopic, or robotic—to being active in the surgical prep and post-surgical wound care process. Rebecca had achieved over 90% of patients using the patient portal and actively participating in data input, record checking, and activity scheduling and reporting. She described how patients were given or sent two sachets of chlorhexidine cleanser, and scrubbed the entire surgical area the night before, and again the morning of surgery. Patients entered this as complete in the portal and were able to report if they encountered any issues in adhering to any of the tasks. The cleansing led to fewer surgical site infections and also just made the patient more aware of maintaining cleanliness. The reporting allowed the surgical nurse to track progress and reach out in time when actions weren’t being completed on schedule. Rebecca explained how this kind of collaboration had led to far fewer rescheduled surgeries, almost no delayed starts, and far fewer postoperative complications. “The portal and its mobile app tie it all together, and we are able to give patients checklists tailored to their specific situation, and to explain what, when, and most importantly, why each item on the checklist is needed.”

Grace looked up from her notes. “What about those who can’t use the portal, … or won’t?”

“About 7% can’t, and 3% won’t, and for them we just go back to a care coordinator nurse acting as a case manager. The nurse phones them, or texts them, or emails them—whichever works best for the patient. On really rare occasions, we get patients that just can’t be reached, and we plan for surprises.” Rebecca explained how the efficiencies created by using the portal and careful prepping created space to adapt and recover when those rare patients needed to be considered. She backtracked briefly. “I want you to understand what a lifesaver it is to have the patients checking their records. Mostly, I’s all clean and the patient vets what we have on them, but sometimes they spot a small glitch that could become a risk, like their height captured as 5’2″ when it should be 6’2″, or their name misspelled. But it’s the rare and potentially catastrophic stuff that gets caught early—like drug allergies. Those catches are worth gold.”

“So where do you still see issues?”

Rebecca looked at her hands. “Not to throw shade on anyone, but the admissions data we get from some of the affiliates is a mess. We spend a lot of time crosschecking because we have seen the full panoply of horrors in some forms—wrong surgery, wrong site, even wrong patient! I just can’t figure it out.”

Grace reflected to herself that Rebecca and her team were instinctively following Lean Six Sigma principles but might get value from a more formal introduction to the concepts and the tools. The way Rebecca thought was very much in line with best practices to avoid the “tyranny of the quantifiable” that led many to focus so closely on KPIs that they inadvertently lost sight of their mission.  She scheduled time for two of Rebecca’s team to be given some PDSA training, access to RStudio, and shown how to use the control chart modules. She also deftly winkled the name of the affiliate with the bad data out of Rebecca.

Back at her office, Grace double checked that the contracts and policies regarding affiliates empowered her to audit them and then set about planning her visit.

It was a hot Thursday afternoon when Grace walked through the doors of the affiliate registration office. Parking had been sparse, the signage was confusing, and Grace noted a lack of disability access or ramp. It took Grace a few minutes to make sense of the long twisting lines of maybe fifty people waiting to book medical services. It was only after comparing the two forms available from a table on either side of the entrance that she realized one line was for medical appointments and the other for surgical. The forms had been pre-filled with either medical or surgical items in some boxes. Clearly, this was confusing to some patients, because as Grace watched, several forms were swapped by the clerks behind the glass partitions. Grace also noted that the clerks routinely had to manually correct items that the patients had filled in and were constantly answering phone calls while doing so. Someone took bundles of forms to the back on a grey metal trolley with a loudly squeaking wheel. Grace tried filling in a surgical form. The pen was scratchy, the block for the date was overly long, the block for last name was too short for “Smithington-Ebenezer.”

Once Grace had seen enough of the bedlam of the front office, she walked to the security guard at the staff entrance and announced herself.

Craig had been an office manager for several years and an administrative clerk for decades. He had heard of Grace and her undercover inspections and had few kind words to say. Not exactly racist or misogynistic, but his sentiments came very close on both counts and were certainly obstructive. He handed Grace over to his deputy, Jerome, and returned to his desk, hidden by a tall metal shelving unit and filled to capacity with stacks of paperwork.

Jerome showed Grace their operational metrics report and said that they were very proud of consistently achieving daily KPIs for forms processed, appointments scheduled, and phones answered within three rings. He used a green highlighter to draw Grace’s attention to these in the printout.

He walked Grace through their workflow. Patients picked up surgical or medical forms that had several parts pre-filled to save time, and since the clerks specialized in either medical or surgical, form processing speed was maximized. “That’s one of our metrics,” he beamed happily. Grace smiled back and asked what happened if the patient had stood in the wrong line or filled in the wrong forms. Jerome frowned, “I guess that does happen sometimes, but the clerks just hand off to each other or correct the forms by hand.”

Once the forms had been filled in and checked, they were batched and taken to the back on a trolley for capture in the hospital system and to schedule a date. Jerome pointed out a batch of forms being taken to the back, and so they followed the squeaky trolley with its juddering wheel while Jerome answered further questions and described the scheduling process.

“Do you shred the forms once they are captured?” Jerome paused before answering, “Well, eventually, but because of verification queries we get, we keep the originals here,” Jerome put a hand on the grey steel shelving unit that towered behind Craig, who was studiously ignoring them. Grace eyed the shelves, mentally calculating how many forms it held. Jerome explained, “This is the last 2 years. Each week, we pull from here and take those down to the basement, where we have up to 5 years of forms. After 5 years, we shred them.”

Grace was almost dumbstruck. “Wow, you guys must be smothered by paperwork!” Jerome shot her a slightly sheepish look and admitted that there was a lot of paper handling, and some days things got tense. He explained how last week the trolley had gone a bit skew and clipped the shelving, so there were lots of forms to pick up and re-sort.

Grace took a brief walk through the rest of the office and then gave Craig and Jerome a rundown of her interim findings. She started with safety and compliance issues—the lack of an ADA-compliant ramp, missing fire exit signage, and the office water cooler was blocking an egress route that ran past the metal shelving and Craig’s desk. She suggested that they immediately move it and then purchase the missing signage before the end of the month. Grace explained that they needed to have the shelving examined, because it was not bolted to the floor, and as best she could see without a ladder, it was not secured to a roof brace either. “And for heaven’s sake, fix that trolley!”

Grace spent another hour going through the wastefulness of capturing patient data twice and then keeping tons of old forms. She explained that direct capture into the hospital system would ultimately be faster, have fewer errors, and remove the need for tons of old forms, which she saw as a security risk, a waste of money, and a fire hazard. Craig pointed out that forms capture and scheduling were two different KPIs, so they couldn’t change the process. “Well, just eliminate those KPIs and create another one to report the new process!” Craig was flummoxed—the notion that KPIs could be eliminated or created fresh was not something he had ever considered.

By the time they were done arguing, and Grace had left, the water cooler had been moved, a purchase order for a new sign had been filled out, and a request for quotes for a ramp had been typed up. Craig took exception to Grace forcing him to move the water cooler, and the moment she left the building, he promptly told his staff to move it back. When they dragged it back, someone had already put some boxes of old forms in the original spot and now the water cooler stuck out a bit further into the passage.

Craig yelled for everyone to get back to work, and he returned to his desk. It was an unfortunate decision, because with everyone feeling a bit rushed, the trolley was being pushed faster, the squeaky wheel made it drift a little further than usual, and it clipped the water cooler with a loud grating sound. The full, 5-gallon bottle fell and skittered across the office floor. At nearly 50lb, it hit the middle leg of the steel shelving, which bent in at an angle. The shelving wobbled, tottered, and then in a cloud of dust, two years of forms cascaded down in a fluttering avalanche, burying Craig and his desk.

By the time his staff clawed away the boxes and sheaves of forms, compression asphyxiation had claimed Craig’s life, and he had literally been smothered to death by paperwork.