BCH’s safety data suggested that during day-to-day activity somebody is stuck with a sharp instrument (e.g., needle or a scalpel) about two times per week (90 to 100 times per year). “Sharps” injuries are painful and risk transferring an infection from the patient to the effected nurse or doctor. Due to that infection risk, after a “stick” the patient’s blood needs to be drawn and tested which requires parental consent, not something that already nervous parents really want to hear.Following good problem solving practice, Carlos focused his project on a subset of the problem, the number of times that a team member was stuck during a surgical procedure. His investigation revealed several significant departures from a regular reconciliation of activity and intent.