Reflecting upon Error


This is a preliminary report of an small interdisciplinary study of application of self-directed reflective thinking to reduction of mistakes and errors. \marginnoteI am deeply indebted to William Gore PhD, Emeritus Professor of Political Science, University of Washington, Meryl Tsukigi, MS of Community Concerns who participated in the weekly discussions, and Erik Samuel Eddy who field tested tools in the community and assisted in internet design and editing. Many others have contributed anonymous reports of using our tools or participated in independent study using the tools. Their suggestions have been invaluable. Originally we worked exclusively with medical error. Health care error produces significant mortality, morbidity and disability. Extensive and expensive administrative, clinical, and research efforts have been applied to efforts to reduce prevalence and incidence. These efforts have been applied to hospitals, clinics and large medical groups. Overall reduction of error has been disappointing. Increasing technical complexity and frequent changes in medical practice and administration are result in failures to produce desired improvement.

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. 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 causes and remedies. We wrote case reports. We reviewed and searched medical, organizational, anthropological, psychiatric and psychoanalytic, and philosophy of science literature\marginnoteThis article is written in Tufte Handout style. Unnumbered notes in the margin are ”margin notes, those with numbers are sidenotes and are repeated in the References. URL’s in either place can be clicked in Adobe Reader, free from Adobe Systems for all platforms. You will be taken to the original reference source, plus usually an abstract and often a free full text copy. We sought ideas for developing relatively simple, grounded, practice level solutions. Elderly readers or those with visual handicaps can also click the + icon at the top in the Adobe Reader window to enlarge text while reading on the computer screen.

These were applied in the trenches of medical care. We developed three open source tools to support reflective thinking, personal resilience, 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 of reduction of clinical error for the practicing health care individual or team. Some people and teams were able to use our most complex tool (Complex Context Critical Incident Report) with very little support or training. Others preferred a more gradual approach to learning. Close observation, improved recall and reflective thinking are built into our less complex tools.

We expanded our efforts to Human Error in general. We need more variety in 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.


Preliminary efforts and literature review led to the creation of Narrative Descriptions. The user was asked to describe an event, and associated emotions. Then a discussion was added with three points of view, personal, interpersonal-communicative, and organizational. Originally these were for discussion within our group. Later we suggested a written narrative focus be added with consideration of probable uses: editing and re-reading, a naive reader, a teaching file, a categorization or an ontology. These could be characterized as goals or WorkPoints Work with Narrative Discussions revealed complexity that required additions for a complete examination of events. We discovered John Flanagan’s early work on the Critical Incident Technique (CIT) (Flanagan 1953), His goal was finding scientific basis for assessment of WWII student pilots who failed in training. Reasons given by examiners were often cliches or lacked depth. The large careful study with well defined goals led to many other applications both in aviation and later in manufacturing, business, management and nursing (Fivars 1980). (PubMed alone has 2543 articles and 231 review articles on CIT in Nursing.) Early attempts to cope with medical error tended to focus on a model of Blame and Train. Considering safety studies from other fields suggested there was greater complexity. To a psychiatrist it appeared there was little attempt to search for problems out of awareness, due to unconscious, denied or unobserved detail. We combined the approach of examining specific events (CIT) with pushing the user to consider emotional reactions and states in our Complex Context Critical Incident Report (CCCIR). The user applies multiple points of view. They include the nature of communication, or lack thereof, and systemic/organizational factors.

We asked users of our reflection tools to include any possible relevant associations: what comes to mind, even if it was a tune, a book, a movie, a distant memory of an event. (Devlin 2014) Keywords are added for future categorization or teaching. WorkPoints \marginnoteWorkPoints is written in CamelCase to emphasize text has special meaning in our methodology. Wikipedia on CamelCase: could indicate ideas to be explored, related concepts, or plans of action or solution. The rather complicated template embraces and clarifies complex situations The final tool was called a Complex Context Critical Incident Report (CCCIR). While users can rapidly learn to use such a template a simpler unit was needed for self-training in close observation and participant observation. Repetitive use also increases recall, associations, and resolves minor impasse.

We call these SwampNotes and they are based on a short (300-400 word) note card. \marginnoteA description of the program that illustrates how word of mouth transmission, clever personal devices and advanced program design support community education and development can be found at

While computers speed up these tools, all that is necessary is pencil and paper. We hope these tools may be useful in worlds as different as academic medical centers and pre-literate tribal societies. Literacy Bridge a clever and effective program produces changes in maternal and child health and agriculture by supporting communication with spoken word devices.


Complex systems have multiple parts. Human use the technical parts and interact with other humans, introducing communication. All this is in constant change over time. I stumbled upon this example on the internet. We could consider the magnets as non-human parts of the system, marbles as humans, and sticks and pieces of wood as designed control factors to keep the components in a safe range. We can see there are many ways things can go wrong and how hard it is to modify one part without unexpected results elsewhere. \marginnoteMarbles and Magnets

Investigating and Defining Complex Systems Failre

This area has been investigated extensively and from many points of view. A summary of important considerations concerning health care is found at the Cognitve Technologies Lab in a handout by Richard I. Cook: How Complex Systems Fail accessible as full text through Research Gate. \marginnote Many additional papers are available through Research Gate where you can select those appropriate to your own interests.

Extending an Investigation

While we began with specific incidents we found in order to have an adequate context we needed both a wider and a deeper look. In the literature this is called thick description an idea introduced by Gilbert Ryle, a philosopher of Mind ,(Ryle 1971)and popularized by Clifford Geertz, an anthropologist, who applied the idea in field work in Bali. (Geertz 1973). In our reflection tools the deeper look is expressed in the Narrative Report, the wider look is the result of the Complex Context Critcal Incident Report. The SwampNote is the basic description of one view of an incident and the author’s view including their feeling state. In repeated use observation and description are sharpened. Several notes may contribute to a narrative of CCCIR.