Reliance on memory a setup for mistakes

Pharmacists certainly need to be aware of unorthodox or unclear abbreviations, but there may be another reason mistakes happen: Doctors, nurses, and pharmacists rely too much on memory.

"It’s one of the most pervasive and fundamental defects in our system," says Lucien Leape, MD, adjunct professor of health policy at Harvard University and a noted researcher on medication mistakes.

Memory represents the weakest of cognitive skills, Leape says. "Everybody forgets things. To rely on short-term memory is a setup to make an error," he says. Plus, memory tends to be highly selective. We tend to remember — and place great attention on — things that only occur rarely. Thus, our attention is drawn away from other, more common problems.

Damned if you do . . . .

Personnel shortages and quick patient turnover increasingly demand health care workers to rely more on memory to get the job done. That’s especially true for doctors, who make far more medication mistakes than pharmacists or nurses. (It’s usually a pharmacist or nurse who sees a doctor’s error and corrects it.) Yet, Leape says, hospitals seem oblivious to the connection between overworked employees and mistakes. "Health care is the only institution in our society that doesn’t seem to believe fatigue impairs performance," he says.

In fact, long work hours and excessive workloads are documented risk factors for errors, as are psychologically taxing work conditions, such as working in a department that runs on intimidation, fear, and mistrust.

Still, working in an "automatic" or memory-reliance mode can be useful for certain tasks, Leape says. Employees need to balance speed and efficiency with thoughtfulness. And for employers, the more speed they expect, the more they need to standardize and simplify systems to minimize mistakes. Leape says he has little doubt that almost any system in the hospital can be simplified.