“I forgot”

My IV machine was beeping for over twenty minutes before I called the nurse. I just didn’t have it in me to ring the bell. “I forgot to do one last step on the machine before I left. I’m so sorry”, the nurse said. That was the third time it happened that day, and no part of me was upset. I forget things, too.

Cognitive load is real.

The mistakes we often make in nursing happen because we don’t make use of what we already know, or once knew. The information exists, but we don’t use it properly.

We err because information is infinite, but our memory, attention and skills are not.

So here’s our situation: Many of us have come to the conclusion that our minor mistakes and near misses don’t matter. We’ve talked ourselves into thinking that we don’t have permission to talk about our failures – and that when we do fail, we just need more education and experience. We’ve been taught to believe that it’s someone else’s job to take initiative and make change happen.

Here’s the truth:

  1. More training and experience isn’t enough to avoid failure. No matter how knowledgeable or experienced we are in our field, we inevitably mess up.
  2. We have permission and a responsibility to develop ways of avoiding failure that overcome our inadequacies.

Is there a common clinical scenario that you always struggle to remember how to approach? You can make a list of steps to follow.

Is there a procedure that no one at work gets right every time? You can write the steps down and work with your team to put them into practice.

Is there a better way of assessing and documenting typical problems you encounter in practice? You can work with your colleagues to create templates and try them out.

Is there a process that bothers everyone you work with? You can bring it to attention and help fix it.

If a person like Atul Gawande can help develop a simple checklist and save thousands of lives, you can too.

The challenge, then, is to develop the habit of seeing opportunities, taking initiative and being brave enough to contribute what others won’t.