Roger Coe Eddy edited abstract.tex  over 7 years ago

Commit id: 7172857375866c6e8408f699697df8617427e804

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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.   We expanded out 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.  \end{abstract}  \pagebreak