2. Time To Pull The Andon Cord

One day, some time in the future, a nurse or doctor will notice something – a piece of equipment, the way a drug is packaged, a problem with a system – and she will (metaphorically) pull a cord to sound an alarm.

The siren that sounds will be a pleasant one and the issue will be made transparent. Staff will congratulate her and delight in the opportunity to help in finding a solution. This solution will be tested, tried, introduced, refined and communicated for others to learn from. Improvements will be made, and patients who may otherwise have suffered, even died, because of the hazard, don’t.

This doesn’t happen in healthcare yet….

The Andon Cord is part of the Toyota Production System. Pulling it means front line staff have their concerns appropriately listened to and managed in a way to ensure continuous improvement and optimum efficiency.

Toyota cars fill our roads because of their reliability. This reliability comes from listening to the front line staff who know best about their individual work environments.

Healthcare doesn’t have an Andon Cord. It never has and as a result the voices of front line staff are for the most part mute.

What happens in healthcare is this: the nurse or doctor notices an issue that can be improved. Most often the thought quickly disappears from their mind – after all there is little they can do about it.

Occasionally however one may be brave enough to try and effect change. They present the issue to those in authority. They may well receive this response: ‘No one else has complained about it’, ‘It’s always been like that’, ‘We’ve never had a problem’, ‘Are you up to the job?’. Nothing is done to effect change.

Push on further and potentially risk your employment. So don’t. Maintain the status quo, keep your job. Meanwhile the inefficiencies and hazards persist and often contribute to medical error.

Medical error is the third greatest cause of death in hospitals.

Some of these errors are reported into cumbersome reporting systems which lack transparency. These systems conceal the errors from others on the front line. Institutions may go to great lengths to keep it that way in part because of concerns about their reputation.

The custodians of the error reports don’t work on the front line. Their best response may be an alert, policy or education framework. The aim of these is to teach the front line staff member how to do their job better to avoid the error. The hazards and innefficiencies that led to the error occurring however are left in place.

All healthcare staff have it within them to recognise and focus on a specific hazard, take a position of leadership, gather a team around them, perhaps utilise a hazard feedback framework and work tirelessly until the hazard is removed.

For healthcare safety it’s time to pull the Andon Cord.

Here’s some unnecessary hazards we’re focussing on – any support is greatly appreciated.

Central lines which open to air
APL valves which trap open
Indistinct pourable chlorhexidine
Valveless intravenous fluid bags


  1. With the right leadership, NHS staff are listened to & learnt from. They create the right environment where errors are talked about & learnt from. Letting the front line lead could save lives & the NHS a fortune. The clinicians & nurses knew what was needed to help my mother recover but the system wouldn’t allow it.

  2. John Kauchick,RN, BSN

    IOM points out that asking questions causes you to be labeled as incompetent. It also said healthcare is comparable to Challenger era NASA. I was doing a best practice in my timeout. I added the fire risk assessment. As part of the reasons given for my termination I was told since that had not been instituted, there it made the other staff feel like they didn’t do their job. Made them uncomfortable. In another complicated case I questioned the positioning of the patient by the fellow. The attending adjusted the traction and ask the fellow why he hadn’t rotated the extremity. In both cases staff complained to management about me. Six weeks into this assignment I went to to the locker room to get dressed and found my is badge had been deactivated. I had to call HR the next day to find out I had been terminated. This is how my 37 year nursing career ended.

    • patientsafe@icloud.com

      John – thank you for your comment. I am extremely sorry you were treated in this way however I’m well aware this is the most likely course for those trying to drive change and improvement.

      My hat goes off to you for trying so hard.

      All my best wishes. Rob

      • John Kauchick, RN, BSN

        The facility was the proud owner of ANA’s Pathways to Excellence designation and on the Magnet journey. When I was there in 2008, 2009 they were on the Magnet journey. Seven years later it was evident they had gotten lost.

Leave a Comment

Your email address will not be published. Required fields are marked *