Day 1

Many things to unpack and think about from today but…

Today while playing the domino game I had a bit of an epiphany about communication and intent. While playing the role of the “nurse,” I was determined to perfectly interpret and execute the intent of the doctor’s instructions. When the finished product wasn’t quite right, my first instinct was to blame myself for not interpreting the instructions correctly. When the roles reversed and I was the “doctor” giving the orders, I again blamed myself for not giving more clear instructions when there was an error in the final product.

In both roles, my intent had been good, if potentially unattainable: to perfectly execute the task at hand on the first try. My partners in the game were similarly focused on achieving success. As such, I knew that any errors made in the translation of the task were not due to an individual’s attitude or noncompliance with the exercise, but were instead attributable to barriers to communication or other “systems-level” issues.

To translate this to the realm of patient safety and communication, it reminded me that in health care, almost everyone involved is doing their best with the sole intention of helping patients. If a nurse writes down the wrong verbal order from a doctor, it’s not because the nurse didn’t want to get it right — something larger is at play. If communication breakdowns occur, while it may be tempting to blame one individual, it’s much more beneficial to look at the system that allowed that error to occur, even if the improvements include individual-level fixes. To reframe Hanlon’s Razor: never attribute to malice that which can be explained by a systems-level failure.

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