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Reflecting upon Error
  • Roger Coe Eddy
Roger Coe Eddy
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Abstract

This is a preliminary report of an small interdisciplinary study focusing on the application of self-directed reflective thinking for individuals interested in exploring how to think about mistakes and errors.

What can an individual, small group, a patient or a care giver, do to reduce the chance of serious medical error often called an adverse event? The focus of this report to facilitate all efforts to deal with medical mistakes and encourage exemplary practices. We concentrated on an individual and small group level because personally, and in our circles of friends and acquaintances many errors and near misses occurred. Emotional immediacy was a strong motivator for us to pursue antecedents and promising remedies. We wrote case reports. We reviewed and searched medical, organizational, anthropological, psychiatric and psychoanalytic, and philosophy of science literature. These were applied in the trenches of medical care. We developed three open source tools to support reflective thinking, personal resilience, and the advancement of knowledge. The tools increased personal and organizational awareness. We welcome comment and suggestions for further development. We seek more examples of personal and small team experience. Our goal is to improve simple, easily applied methods for evaluating and comprehending how to best reduce errors for a health care team or an individual in practice.

Although we have expanded our efforts to Human Error in general, we are in need of more variety in collected examples. Other areas such as aviation provide useful comparisons and differences. We found what we had discovered, while incomplete, had broader applications in daily living. Embedded resistances in individuals and systems are difficult to reveal and change, more data expands our points of view.