Roger Coe Eddy edited begin_section_Introduction_Preliminary_efforts__.tex  over 1 year ago

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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. \cite{Devlin2014}  Keywords are added for future categorization or teaching. \emph{WorkPoints} \marginnote{WorkPoints \marginnte{WorkPoints  is written in CamelCase to emphasize text has special meaning in our methodology. Wikipedia on CamelCase:{\url{https://en.wikipedia.org/wiki/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.