Reflecting upon Error


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. \marginnoteI am deeply indebted to William Gore PhD, Emeritus Professor of Political Science, University of Washington, Meryl Tsukiji, MA of Collective 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 by using our tools either as participants in independent studies or by anonymous reports. Their suggestions have been invaluable. Originally we worked exclusively studying medical errors. These errors can result in significant mortality, morbidity and disability outcomes that are both identifiable and quantifiable. Extensive and expensive administrative, clinical, and research efforts have been applied to efforts to reduce the prevalence and incidence of medical mistakes. These efforts have been applied to hospitals, clinics and large medical groups. However, the overall reduction of error has been disappointing as increasing technical complexity, and frequent modifications in medical practices and changing administrative priorities complicate initiatives 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 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\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, 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.


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.

Our beginning trials with the Narrative Discussions revealed a complexity requiring a more complete examination of events. We discovered John Flanagan’s early work on the Critical Incident Technique (CIT) (Flanagan 1953), His goal was to develop a scientific basis for identifying critical factors to account for WWII student pilots who failed in training. Previously reasons given by examiners were often cliches or lacked depth. This 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 however, safety studies from other fields suggested there was greater complexity. To a psychiatrist it appeared there was little attempt to search for problems outside 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). In this new approach the user applies multiple points of view to include feelings and emotions, 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 with some support even naive users can rapidly learn to use such a template a simplified unit was needed for self-training in close observation and participant observation. Repetitive use also increases recall, associations, and resolves minor impasse. We have some optimism that a future system could be developed utilizing more productively the world wide web, social media and hypertext elements.

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.


Literacy Bridge
A 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


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. Use the link to the video and click on the arrow to show the operation of a model of a complex system. If you can, use the full screen view. Note there could be a cascading series of minor defects in the system that could result in a complete breakdown. We will return to that idea. Also note that while the marbles are almost passive once they are set in motion, humans can observe and react in complex processes in which they find themselves. Richard Cook in the next section feels this is how expert participants can pick up errors in progress and intervene to change the course of events. To perform in that way they must have learned thru mistakes. That is how knowledge is acquired and generalized to new situations.

Investigating and Defining Complex Systems Failure

This area has been investigated extensively and from many points of view. \marginnote[-2] Many additional papers are available through Research Gate where you can select those appropriate to your own interests. 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. One of the problems of research in this area is the view from the top down is strongly influenced by the language and habits of the different disciplines, they are looking for a particular canary in the coal mine, one from the areas with which they are familiar and were they can develop testable hypotheses. From the ground, the bottom up, the case report, the life story, the perspective is somewhat different. We do not want to miss something just because it is new, or rare or unfamiliar to us. One of the most troubling problems in medicine is the patient who presents with something unexpected or unknown to us. They are frequently blamed for not having the right picture to fit our expectations. They are blamed for imagining something or come to feel they are hypochondriacs. One of my OB/Gyn professors drummed into our minds the ”first symptom of carcinoma of the cervix is no symptoms.”

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. \marginnoteSwampNote is a term we began using fifteen years ago. We found the idea in the work at MIT of Donald Schon. He contrasted the different worlds of the academy and work in the trenches which he called the Swamp. In recent years the term has become so loaded in political and media discussion that the original meaning has become smothered by a new one. This is not uncommon that language changes or loses meaning and is no longer as useful. Famously that was illustrated in Anmimal Farm and 1984. As this became clear to us we had already tried another original term of our own OoopsaDaisy for a note based simple system. In practice it is not important what it is named or called but it is important that it not frighten or intimidate users. Other ways of dealing with blurred language usage are the CamelCase new words and the small caps used by Tufte and the capitalized common words used for basic emotions by Jaak Panksepp. In repeated use observation and description are sharpened. Several notes may contribute to a Narrative Report and/or a CCCIR. We provide samples of the tools in Section 4 and clarify how they relate to each other and how they can and should be adapted to local, on the ground conditions. The next sections explain what situations and questions led us to develop this way of looking at important life incidents.