Sample “Project” - “A Remedy for Errors”
I am cautiously volunteering the examples here as Mark A. seems frustrated in that it is tough to get real life samples to work with. Please do NOT distribute these beyond the Tinderbox community and treat them with respect as you would wish to be treated if you were the doctor, nurse or patient described. I have included a sample from retail business as well. Any comments about tinderbox in action or the project itself are welcome, if you want to send a private message <nitelogger@me.com>t
The sample files can be downloaded from my Dropbox account public folder: <
The outline from CT lab summarizes data about medical error.
https://dl-web.dropbox.com/get/Public/Tinderbox%20stuff%20%28ARFE%29/BriefLookAt...There are two tinderbox files:
https://dl-web.dropbox.com/get/Public/Tinderbox%20stuff%20%28ARFE%29/Narrative%2...https://dl-web.dropbox.com/get/Public/Tinderbox%20stuff%20%28ARFE%29/Novice%20to...A .jpeg of a tinderbox map of “user experience”:
User experience v2 part1.jpg 783×650 pixels
A keynote presentation used with medical residents that shows how the material is introduced to health care professionals.
http://dl.dropbox.com/u/251672/Tinderbox%20stuff%20%28ARFE%29/residents.keyA Field Guide to Human Error with light hearted tone to soften up resistance to thinking about human error.
https://dl-web.dropbox.com/get/Public/FINAL2011Field%20Guide.pdf?w=72ac9446About myself - I am a 76 year old psychiatrist/psychoanalyst/medical educator retiring this year after about fifty years of practice including government and community consultation. Over the past ten years I have been part of a four person group working as a scientific hobby on the problem of medical error and patient safety. This has been a part time, uncompensated (to say the least) effort and independent of our professional and academic positions and obligations.
About the problem -
The problems are complex, overdetermined, interdisciplinary and extremely resistant to change and correction due to many deeply embedded “resistances” at all levels of activity, politics, professional egos, disagreements within and between professional and other groups and on and on.
The medical error situation briefly summarized would be a death rate equal to two jet crashes per day, or a 6% probability of a problem causing significant disability per day of hospitalization. Over the past ten years millions of dollars in studies and grants have been spent on research and attempted correction. Improvements have been moderate at best. Studies have been replicated in other countries and using both retrospective and prospective studies. However the results are only reluctantly accepted and progress is slow.
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In working in this area we found there were two main questions that came up repeatedly.
Why do people keep repeating actions that do not achieve the desired result and resist suggestions for change?
Why do organizations hire consultants and engage in extensive efforts at self-observation only to ignore or defeat the recommendations they obtain?
Then there is the problem of how do we put what we learn into our knowledge base(TBX helpful here) and into useful, practical action items for the user or the organization seeking consultation.
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Our group has developed three “tools” that have been used in training and teaching various groups. I am the only physician the other colleagues having backgrounds in political science, administration and writing. We have been effective in working with small groups of colleagues or students. Difficulties almost immediately arise about trust, confidentiality and legal and malpractice issues. These are not easily addressed. Our deliberate focus has been on what could the individual, patient, practitioner, do to reduce the probability of being a victim of a medical error. What can be done practically “in the trenches” to improve quality of care or practice? (There are many other very well funded efforts at the organizational, systemic level, some of which work.)
Our tools have been designed to be used at different levels of cooperation and sophistication, from the novice to the expert:
OOOPSADAISY - write a brief description on a file card, like “Hipster” and reflect on it.
Narrative reports - select significant incidents and append a discussion. At a more advanced level be prepared to share the incident with a buddy.
Complex Context Critical Incident Report (CCCIR) a narrative, a discussion, some key words, three points of view, organizational, interpersonal-communicative, and individual, a report of feelings, action items, references to “the literature” or any other media that help understand the experience.
Users who have applied the tools have generally found them useful.
Description of TBX documents continued in following post due to character limit.