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. 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 their chances of the effects of medical error? The focus of this report is on efforts to deal with medical mistakes. 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 to pursue causes and remedies. We wrote case reports. We reviewed and searched medical, organizational, anthropological, psychiatric and psychoanalytic, and philosophy of science literature. We sought ideas for developing relatively simple, grounded, practice level solutions. These are found in the trenches of medical care. We developed three open source tools to support reflective thinking, personal resilience, advancement of knowledge. We incidentally found 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.


Preliminary efforts and reading 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 wriiten 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), (Fivars 1980). His goal was finding scientific basis for assessment of pilots. 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 much 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 also needed to apply multiple points of view other than their own and attempt to describe the nature of communication, or lack thereof, and systemic and organizational factors. We also 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 should be 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 and the final tool was called a Complex Context Critical Incident Report (CCCIR). While users can fairly 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 sometimes resolves minor impasse. We call these SwampNotes and they are based on a short (300-400 word) note card. While computers can 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.

Reflecting upon Error

Our small group, a psychiatrist/psychoanalyst, a political scientist, an 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. We 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 (Brennan 1991)(Leape 1991) (Stange 2001)(Stange 2011). Our 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. We were dissatisfied by the narrowness of our own interpretations. We accepted there were many unknowns we needed to understand. We were all familiar with the problems of working in interdisciplinary and even ethnological environments. We felt our experiences might be complementary.

Early questions and findings

In early meetings we compared problems in acceptance of recommendations of consultants and assignment of causes to medical errors.

  1. 1.

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

  2. 2.

    Why do systems blame individuals and individuals blame systems?

  3. 3.

    Why do individuals and organizations suffer memory failures?

  4. 4.

    What are the sources of institutional resistance to learning and how can they be addressed?

  5. 5.

    What tools can we develop to clarify these questions?

  6. 6.

    How do brains/minds and computers learn, or not, thru information, apprenticeship, identification, and experience?

  7. 7.

    How does our training or academic discipline limit our thinking?