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  • 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 many changes in medical practice and administration are contributing causes to failures of changes to produce desired improvement.

    What can an individual or small group, a patient or a care giver do to reduce the chance of serious medical error (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.

    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 work points 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 them 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. Work Points 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. 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. \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

    Reflecting upon Error

    Our small group, a psychiatrist/psychoanalyst, a political scientist, a consultant in public administration, and a college student with computer and interviewing skills worked together in attempting to address the problems of patient safety and medical error.(Brennan 1991)\newparaWe were concerned with the practical, grounded, problems of individuals and small teams trying to reduce the serious harms caused by medical error. These issues had recently been brought to the attention of health care professionals (Leape 1991)\newparaOur interest was also emotionally driven by errors and near-misses in our care and the care of friends and loved ones. We were all frustrated in trying to understand the complexity of grounded, clinical examples.(Stange 2001)We were dissatisfied by the narrowness of our own interpretations. We accepted there were many unknowns we needed to understand(Lanham 2016). We were all familiar with the problems of working in interdisciplinary and even ethnological environments. We felt our experiences might be complementary. A widened view of health care in the community as it actually exists in practice is becoming more urgent. Costs rise and prevention requires more attention.(Lanham 2016)

    Early questions and findings

    In weekly early meetings we compared problems in acceptance of recommendations of consultants and assignment of causes to medical errors. We used brief narrative case history examples. A number of questions emerged.

    1. 1.

      Why do organizations performs studies of themselves, receive recommendations, but fail to act on them?

    2. 2.