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\begin{abstract}
This is a preliminary report of an small interdisciplinary study
of focusing on the application of self-directed reflective thinking
for individuals interested in exploring how to
reduction of think about mistakes and errors. \marginnote{I am deeply indebted to William Gore PhD, Emeritus Professor of Political Science, University of Washington, Meryl
Tsukigi, MS Tsukiji, MA of
Community 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
anonymous reports of by using our tools
or participated either as participants in independent
study using the tools. studies or by anonymous reports. Their suggestions have been invaluable.} Originally we worked exclusively
with studying medical
error. Health care error produces errors. These errors can result in significant mortality, morbidity and
disability. 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. incidence of medical mistakes. These efforts have been applied to hospitals, clinics and large medical groups.
Overall However, the overall reduction of error has been
disappointing. Increasing disappointing as increasing technical
complexity complexity, and frequent
changes modifications in medical
practice practices and
administration are result in failures 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 \emph{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 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
causes antecedents and
promising remedies. We wrote case reports. We reviewed and searched medical, organizational, anthropological, psychiatric and psychoanalytic, and philosophy of science literature\marginnote{This 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
of reduction of clinical error for
the practicing evaluating and comprehending how to best reduce errors for a health care
individual team or
team. an individual in practice. 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 Although we have expanded our efforts to Human Error in
general. We 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.
\end{abstract}
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