Many healthcare interventions fail to produce the intended effect. In this paper we look back at the fasting-time project, which aimed to shorten patients’ preoperative fasting times. However, the project failed to achieve this effect, even though it had been identified and prioritized by the clinicians at the studied hospital. A set of mutually reinforcing factors collectively explain why the project failed to produce change. The four main factors are: lack of urgency, risk aversion, day-to-day busyness, and lack of managerial commitment at the department level. The simultaneous presence of these factors complicates efforts to counter them.