Iman Abukar and I discuss why what may feel to a nurse to be a routine assessment is so important. Nurses are constantly assessing; much of it is subconscious and on autopilot. In each specialty and for each condition there are routine things to monitor and assess for. We are the providers' eyes and ears. We need to be on the lookout for when our assessment skills tell us that a complication may be occurring and pass the information on to the provider. By not following a standing order and routine nursing intervention for the floor, a missed that opportunity and tragedy struck.