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Monday, May 2, 2011

Opps! How to Make Fewer Mistakes at Work and at Home

To err is human; to develop a strategy to make it less so is divine. Lightarted Sue

Our Father Who Art--Where?

I was taking my first sip of coffee as I opened my email to see a message from my sister with the unsettling headline:
"DADDY IS IN GOD HANDS AT EL CAMINO HOSPITAL"
What? He had just gone into the hospital the night before with a cough, and he was doing just fine. How could this happen? This can't be right. With my heart racing, and my mind now fully awake, I quickly clicked the email to view the entire message.

My sister's message went on to say,
"Daddy is in great spirits and in good hands. They are doing blood cultures, EKG, chest x-ray, and more. Love, Daddy's favorite daughter"

A Mere Trifle of a Typo

It took me a moment to settle down, and take in what happened. One trifle of a typo--the omission of a single letter "o"-- had hugely changed the opening message, and my brain had further corrected the message to read my father was in 'God's Hands'. It didn't help that the message was in all CAPS.

I immediately rang my "father's favorite daughter" and asked, "Are you trying to upset me this morning?"

"Why? I just sent out an email to the family about Daddy."

"Yes, I know--that's what I'm calling about."

"Why? -- I said Daddy's in good hands at the hospital."

"No, you didn't. You said he was in God Hands."
There was a big pause before she laughed. "I didn't get home from the hospital until midnight. What can I say--I was tired when I typed it.

And therein lies the problem, she wrote the message when she was tired, and I received the message when I was barely awake.

Your Brain is Creative, and Wired to Make Mistakes

This mini-mistake by my sister, whose only intention was to inform her family in a timely fashion, was one more example of 'to err is human'. It's so easy to do.

Our human brains, it seems, are designed to be creative, and therefore wired to make mistakes even under the best of conditions. But when we're tired, hungry or upset, it's even easier.

My Brain Doesn't Make Errors!

Sure it does. Everyone's brain is wired to make errors...that's the downside of its ability to be creative. Test your brain's wiring now. Look at the picture--is it moving or standing still? This is a 'still shot', not animated. If you see it moving, it is your brain creating the movement, or error in perception.



Typo? Typo? I Don't See No Stinkin' Typo!

Because our brains are wired to make mistakes--kind of like fuzzy logic of the brain-- it's often difficult to catch typos. Our brain knows what the word is supposed to be, and it corrects it for us as we read through what we wrote. Let me show you.

Can You Read This?

Aoccdrnig to a rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer in what oredr the ltteers in a wrod are, the olny iprmoetnt tihng is taht the frist and lsat ltteer be at the rghit pclae. The rset can be a total mses and you can sitll raed it wouthit porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. Amzanig huh?

You can see why it might be difficult for my sister to find one single 'o' omitted from 'good' when she's tired, and why it was easy for me to read God's Hands when presented with God Hands.

Teeny-Tiny Mistakes with Huge Consequences

While the omission of one 'o' in my sister's message created a bit of angst for me, it didn't have the type of longer lasting consequences created by a misplaced decimal point in a medication dose or on a mortgage or tax payment.

In the medical community, preventing medication errors is a big deal. It's especially important for medical professionals to develop and implement error prevention strategies to offset the brain's natural tendency towards making mistakes.

A ten-fold medication error can be made when a dosage is written with a zero that follows a decimal point. When 1 mg dose is written as 1.0 mg, the reader can fail to see the decimal point and interpret it as 10 mg. Likewise, if a physician quickly writes 10mg for 1.0 mg, omitting the teeny-tiny decimal point you have the same ten-fold medication error.

When I was in college, I came down with a very painful sinus infection while visiting a friend in Arizona. His doctor saw me and wrote me a prescription for 10 pills of 100mg of of a common antibiotic to take to the pharmacy. Unfortunately, when the pharmacist handed me a bottle with 100 pills instead of ten, I knew there was a mistake. The physician had written the prescription incorrectly, transposing the numbers to be 100 pills of 10 mg. I had to wait hours until the pharmacist reached the physician to correct the prescription.

But the medical community isn't the only place where little errors can have big consequences. One year, I had a year-long battle with the IRS due to an inputting error by a clerk. I submitted a check for $2,770.00 that was incorrectly put into the system for $277.00. Again, one teeny-tiny decimal point put in the wrong place created a problem that took hundreds of hours to undo.

I Make All My Mistakes Very Carefully...and You Do Too!

No one sets out to make mistakes. Usually we work very hard to get it right--especially when it's important to do so. But with our brains wired to make errors, we need to accept it's virtually impossible to do everything perfectly on our own.

I make all my mistakes very carefully--and you do too. The harder we try, the more some little detail eludes us. That's why I need to implement strategies to prevent costly mistakes that enlists the help of others--and you do too!

Simple Ways to Reduce Errors at Work or Home

1. Whether you're doing your best to get it right at work or at home, accept your brain is wired to make mistakes and develop a strategy for making it less so.

Anywhere you need to get it right---when cooking, building houses, paying your taxes or mortgage, dispensing medications, correcting computer bugs, or just sending informative emails to your family--you will benefit from applying a few simple techniques.

2. If you check your own work, take time out between doing that calculation or writing that email and when you recheck it for accuracy. Why?

You are more likely to find your own errors when you put time between rechecks.

My mother used to say 'make time work for you'. Here, you make time work for you by giving your brain a rest from concentrating on getting it right. Engage in other activities--take a walk, do the dishes, read a book---anything unrelated to the task you're trying to get right. Then with a relaxed, calm mind recheck your work for accuracy. You'll see with fresh eyes.

3. When it's critical you get it right--especially in high risk areas--such as dealing with high alert medications or legal documents-- implement double checks. Double checks means engaging the help of others to double check with you. Why?
Your brain sees what it expects to see.
So when you write that email and attempt to quickly check it for mistakes before hitting the send button, your brain sees what it expects to see making it difficult to find your own mistakes. This is true for other things like calculations and measurements too.

If you measure lumber to the specifications in the building instructions, before cutting, have your partner measure it again and call out the results to you as you check it against the written specifications. Measure twice, cut once---and double check it with the help of others.

Or to implement double checks for nursing, have one nurse read what's on the medication package or dose, while the other nurse checks it against the order, then reverse the process.

Nobody's perfect. We are going to make mistakes.  By accepting that your wonderfully creative mind is wired to make mistakes you can choose to act in ways that make it less so.

P.S. 'O' Well--Did you catch the omitted 'o' in the title? OPPS is actually spelled OOPS!

6 comments:

Grant said...

Hey Sue, great post and I love your quote "To err is human; to develop a strategy to make it less so is divine". Knowing how to overcome our very normal human limitations and propensities for error when we are rushed or tired is vitally important. As you point out, by putting in place appropriate strategies we can ensure we do things the way we want each and every time. Thanks for bringing this incredibly useful way of thinking to our awareness.

cheers and smiles
Grant

Jean | Delightful Repast said...

Sue, this is an excellent post for all of us. Your sister's typo was terrible, but I'm glad it was a typo! Especially when people are having costly brochures printed, I tell them to have a number of qualified proofreaders check it first.

Susan J Meyerott, M.S. said...

Hi Grant!
This is something I need to apply regularly. Knowing our brains are wired to make mistakes helps me appreciate the importance of choosing to understand, not misunderstand; teamwork and asking for feedback; and practicing the pause.

Always appreciate your comments (and your blogs).

Kindest Regards,
Susan

Susan J Meyerott, M.S. said...

Jean--
Good to hear from you. Proofreading is always a challenge. True to my comments in the post, I still found a typo at the end I had to edit after posting. Sigh...Of course I didn't do what proof readers are supposed to do--read backwards to catch those typos.

Kindest Regards,
Susan

Cynthia Kendall said...

Sue, I love this post. I will try to do better on not making mistakes for they can be costly. Love you!

Susan J Meyerott, M.S. said...

Cynthia! Mistakes are good. Just remember to make all your mistakes very carefully! Sue