Our small group, a psychiatrist/psychoanalyst, a political scientist, a 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.\cite{Brennan_1991} 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. 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. A widened view of health care in the community as it actually exists in practice is becoming more urgent. Costs rise and prevention requires more attention.\cite{26611650}
In weekly early meetings we compared problems in acceptance of recommendations of consultants and assignment of causes to medical errors. We used brief narrative case history examples. A number of questions emerged.
Why do organizations performs studies of themselves, receive recommendations, but fail to act on them?
Why do systems blame individuals and individuals blame systems?
Why do individuals and organizations suffer memory failures?
What are the sources of institutional resistance to learning and how can they be addressed?
What tools can we develop to clarify these questions? \cite{11322522}
How do brains/minds and computers learn, or not, thru information, apprenticeship, identification, and experience?
How does our training or academic discipline limit our thinking?