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What's the big deal, just forget about it

Renata Martinez

Category:

Investigations

Have you ever walked into a room and forgot why you were there? Or looked for your sunglasses while they were on your head? It happens to me all the time. I forget – ask my husband. I forget to put the clothes in the dryer after the wash cycle. I forget to turn off the water when spot treating the lawn. I forget to pick up Rory’s favorite type of bread at the grocery store. My Dad calls it “CRS”, stands for “can’t remember stuff”. (And “stuff” is the word he always used….)

What’s the big deal - why does forgetfulness matter? Everybody is forgetful from time to time, but in the workplace forgetfulness can cause steps in a process or procedure to be missed. It can cause safety issues. It can cause delays. It can cause rework. One forgotten thing can have a handful of negative consequences and it’s usually completely unintentional...except maybe when I “forget” to pick up extra batteries for my niece’s Frozen Sing-A-Long microphone!

If you get to a point in an investigation where one of the causes is simply someone forgot something, what is an effective solution? “Don’t forget again, okay Renata?!” Well, I probably won’t forget that specific step that I missed ever again because I could have really hurt someone. I already feel embarrassed and bad about forgetting so telling me not to forget won’t be that effective. What about the next person performing this task who hasn’t had this near miss experience? How do they know to “remember”?

Fixing Faults

Effective solutions will essentially be literal “traps” that change the work processes to help employees remember or create a device that prevents them from proceeding until certain steps are performed. Before you get to solutions though, you need to understand the process and identify what those key steps are. Involving those who commonly execute a task or were involved in an incident will be key into understanding the details (what all is required to complete the task, what is critical, etc.).

Once the process or task is understood key steps, traps and triggers can be identified.

Failing to Forget

A little background, I hate 90% of leftovers. I only make leftovers because Rory, my husband, likes to take them to work for lunch. Well, the other day when I threw out quite a few moldy Tupperware containers of forgotten leftovers, I became annoyed.

How could he forget his lunch so often? I told him last week NOT TO FORGET! He told me that he’s usually in a hurry; letting the dogs out, making coffee, showering, taking out the trash on Mondays, recycling on Thursdays, feeding the dogs, grabbing his golf or softball clothes for after work…he’s a little distracted. Oh, and he doesn’t open the fridge for anything in the morning so he doesn’t see the food to help him remember to grab it.

Develop the work processes

So, what did we do? Now we tie a string to his keys and attach the free end to the meal in the fridge. He takes his car every morning, he can’t leave without grabbing his keys that are tied to the refrigerator, reminding him to take his lunch. We created a physical barrier to prevent him from leaving without the leftovers.

Create a barrier

Locks applied during energy isolation are other examples of ways to ensure certain steps of a work process are done in the correct order. If people forget and try to move a valve or send a start signal, the physical lock prevents movement.

Make a checklist

Checklists are another valuable tool to help people remember key steps. One of the reasons that commercial airline flights are so safe is that the pilots, even though they are highly trained and have done the same tasks many times, always use a checklist to help them remember what needs to be done.

Fix it and forget it

Building reminders into the work processes help the people who are performing the tasks not to forget key steps, ultimately leading to more reliable and consistent work practice(s). We’re human and we all make mistakes so we need tools, checks, barriers to help us. The next time you’re investigating a human performance issue, don’t stop at “forget” or “procedure not followed”. Involve the employee(s) to document their work process(es) and understand what can be put in place to help them.

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