There's nothing like a three day weekend to recharge your batteries (especially when it's a three day weekend at the beach!)! So, in other words, I was feeling pretty relaxed this morning when I drove in to work. Not a care in the world. Ready to take on every challenge with verve and vigor. Bring it on!
Well...as the saying goes, easy come, easy go. Somehow, I managed to lock the keys in my car. As a matter of fact, I didn't even realize it until I got up to my office and reached in to my pants pocket to grab my keys and unlock my door. Uh-oh. Where are my keys? I looked in my other pants pocket. Nope. I looked in both of my coat pockets. Not there either. How about in my backpack? Nope. Not there. Hmmm. Could I have left my keys in the car door? I doubt it, but I better go look. Just in case. Oh. There they are. Still in the ignition. Wow, how did I do that?
I know what you are thinking. And you are right. I am a doofus. You are also probably saying to yourself (I know most of my co-workers told me this), "Most cars don't let you do that." Well - this one did!
As I started to retrace my steps and conduct my own mini-After Action Review, it suddenly all made sense. I broke up my normal routine this morning. I usually walk our dogs first thing in the morning before leaving for work. When I am out, I grab the newspaper, take it out of its plastic bag, and throw it in my backpack (with all of my other papers - remember, I have a pathological condition known by the Japanese term, "Tsundoku"). Well this morning, my normal routine was all different. The dogs were still at the kennel (we got in too late last night to pick them up). No dogs = no early morning walk = no newspaper. Today I drove down the driveway, stopped to pick up the newspaper, and threw it in my front seat. I also had some other things that I had placed in the front seat that I wanted to take to work. When I got in to work this morning, instead of grabbing my keys, closing the driver side front door, and opening up the driver side back door to grab my stuff, I must have grabbed the things out of the front seat, closed the driver side front door, opened the driver side back door, and grabbed my stuff. I always hit the door lock before I close the front door, which I did this morning. All the doors locked. I grabbed my stuff, closed the back door, and off I went. No car keys.
It's amazing to me that I do something almost exactly the same way every single morning to the point where I don't even stop to think about what I am doing. My routine is so routine, that I use very little brain power to go through the exact same sequence of steps every single day of the work week, year in and year out. I think I've probably followed this exact same sequence of steps at least a couple of thousand times, if not more. Change my routine just a tiny bit and everything falls apart! I made, what Patient Safety professionals would call a "slip" (according to the Center for Patient Safety, a slip is defined as "a failure of schematic behavior or a lapse in concentration", usually in the face of a competing priority, distraction, or fatigue). I made a classic slip. You may or may not have done the same thing - for example, have you ever placed something in the refrigerator that clearly doesn't belong there? That's a slip. The Agency for Healthcare Research and Quality recommends, based on a wealth of experience and proven track record in the aviation industry and in health care, the use of checklists to prevent these kinds of mistakes.
Think about it for a minute. Checklists have been shown to be the most effective for exactly the kinds of scenarios that I described with my daily morning routine - a sequence of steps that have been performed over and over and over hundreds, if not thousands of times. Pilots run through a checklist before take-off. They've probably performed the steps so many times that they really don't need a checklist, but they use them to prevent that one minor slip that could turn into a major catastrophe. Similarly, operating room teams run through checklists before every surgery to make sure that they have the right patient, the right equipment, and the right planned procedure. Physicians and nurses use checklists whenever they place central lines or change the central line dressing, in order to significantly reduce the risk of a central line infection. Checklists may not be applicable in every situation, but they are very effective in preventing slips or lapses when performing distinct processes that have become routines.
My own personal lesson this morning reinforced the need for checklists when performing everyday routines! And I was once again reminded of the fact that my wife is a saint (she did marry me, of course, but she also drove WAY out of her way this evening to bring me the spare set of keys). The vacation is officially over, but the lessons keep coming.
No comments:
Post a Comment