Roger Coe Eddy edited par_textbf_Institutional_Resistances_begin__.tex  about 7 years ago

Commit id: da59fb673f344a8d8ebcbba6001dd7465f78b895

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\par\textbf{Biased Approaches to Life Events}  \begin{quote}  7a. In reviewing descriptions of incidents, errors and case studies we commonly noted the academic discipline, profession, and background of investigators biased their choices of significant data. They ignored aspects of events obvious to us. Somewhat later we noted we were also doing the same thing. One of our tasks would be to break down observations into smaller units that could be globally described, but closely observed. Another was to state our biases and in designing tools aim to push the user to do the same. They would need to report on aspects of incidents they quite naturally ignore.  7b. Hindsight Bias. Often studies of medical error are based upon reviews, long after the fact, of hospital records. With the advantage of looking back at the past errors may be compared against best practices. Such reviews may lack the perspective of what was the perceptions of the situation at the time of the incident. This may be particularly hard to accurately describe in complex situations such as operating rooms and emergency care. On the other hand an individual may gain a great deal looking back with time and space to reflect on what could have been done differently. This type of problem is often seen where there is an attempt to fix blame for the event.  \end{quote}  \begin{quote}  \pagebreak