We Are Human, After All

“The No. 1 rule in nursing school is don’t make a mistake. But we are human, after all. We make mistakes,” said Al Duke, who presented “If ‘To Err Is Human,’ Why Am I in Trouble?”

In the Friday session, Duke shared wisdom about organizational culture gleaned from malpractice claims he has reviewed.

The challenge for emergency room nurses is that they must think fast and act quickly, he said. These two requirements demand efficiency over thoroughness. In a world where there are two types of thinking—System 1 and System 2 thinking—nurses often have to act by rote.

System 1 thinking is recognizing patterns or symptoms and then moving to the best known solution. “It doesn’t take a lot of brain power. You could do it in your sleep,” he said.

System 2 thinking, on the other hand, is more analytical and takes processing power.

He likened it to when he first learned to drive. “My first time behind the wheel, I was conscious of how hard I pressed the accelerator and all of the other factors needed to drive. However, now, I hardly even think about it.”

Duke maintains that systems and organizational culture break down when mistakes happen and need to be fixed with new processes, workarounds and checklists, not judgment.

“We need to fix the system, not necessarily the human. Nurses pursue this profession because they want to help; they do not want to do harm.”

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