During the early 2000s, Allan Goldman, M.D., a chief physician at the Great Ormond Street Hospital, a children’s hospital in London, observed that too many mistakes were being made when patients were transferred from surgery to ICU. It seemed that no one person was specifically in charge of a patient hand-off, and confusion would arise as several people exchanged vital information all at once.

The process was slow, inefficient, and occasionally disastrous—such as when a patient, needing assistance with breathing, arrived in ICU before the ventilator was set up.

Then one day after watching a Formula One automobile race, Goldman noticed similarities between patient transfers and a race car making a pit stop. The race car crew was able to change tires, refuel, clean vents, and more in 7 seconds. The process was systematic and precise. It was exactly what the hospital needed, and he decided to consult the Ferrari race team to help design an efficient patient transfer protocol.

The people from Ferrari helped develop a three-step procedure to complete patient transfers, and the result was a decrease in technical errors of 42 percent, and a decrease of clinical information omission of 49 percent.

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