This case begins by telling about what happened to a woman named Carmen when she thought she may have been having a heart attack so she called 911. After answering a number of questions, the operator transferred her call to a doctor. She had to explain her situation again and answer even more questions. Then the ambulance came, where she answered the same questions again. Next, she went to the emergency room where a different doctor asked her the same questions, some tests were done and then told her she needed an X-ray. Unfortunately, after waiting two more hours, she was told that she the tests needed to be redone because the doctor hadn’t signed the authorization for the first ones. She finally got the results and although everything was normal, she still had to be admitted for further tests. Due to a shortage of beds, she had to be moved to another hospital (General Hospital). But she still did not get a bedroom and had to go through the process of answering the same questions for a doctor and nurse again…

Lopez Vega, a cardiac surgeon at General Hospital, and his colleagues agreed that the way patients were handled needed to be changed. In order to make improvements, they did a failure mode effect analysis in order to expose recurring errors and inefficiencies. At the end of the case, readers are asked to analyze the hospital service chain problems they saw in Carmen’s story and the process flow diagrams with the associated failure models. Then they are asked how they would apply the recommendations to eliminate or reduce the root causes of process failure.