The second example, from a project with Kaiser Permanente, addressed gaps in communication at nurse shift changes. The shift change is the genesis of a large percentage of medical errors because it is hard to transfer every bit of knowledge. One outcome was a bulletin board in the patient room in the maternity ward with a simple set of tiles hung on hooks. Each tile represented a milestone to complete before the patient could go home with her newborn — things like immunizations and filling out the birth certificate