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C7RKY's profile
John Clarke
John Clarke
John Clarke
@C7RKY

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John Clarke

@C7RKY

Of course views all mine. All without prejudice. Just a regular chap after all. Oh...and RT's may equally imply ridicule as endorsement.

UK
Joined December 2011

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    1. Ken Lownds‏ @KenZeroHarm Oct 22
      Replying to @Cjw450Cathy @AlisonSJones5 and

      ZHH It’s deeply disturbing to me as a patient + member of the public!!

      2 replies 0 retweets 0 likes
    2. Cathy Welch‏ @Cjw450Cathy Oct 22
      Replying to @KenZeroHarm @AlisonSJones5 and

      1/4 Stop and think about something close to home, a pot-plant for instance. You know the basic rules- water and feed regularly, place it in light/shade according to instructions. But it starts to wilt...

      1 reply 0 retweets 0 likes
    3. Cathy Welch‏ @Cjw450Cathy Oct 22
      Replying to @Cjw450Cathy @KenZeroHarm and

      2/4 You followed all the standardised instructions. So you find some expert guidance about plantcare... suggests higher optimum temperature, so move it closer to radiator...it livens up, then leaves start to brown...

      1 reply 0 retweets 0 likes
    4. Cathy Welch‏ @Cjw450Cathy Oct 22
      Replying to @Cjw450Cathy @KenZeroHarm and

      3/4 You’re watering it, feeding it, doing everything the instructions and experts say, but it still withers and dies. So you bring in an expert to find out why... they look at all the watering and feeding schedules, temperature recordings, sunlight levels...

      2 replies 0 retweets 0 likes
    5. Cathy Welch‏ @Cjw450Cathy Oct 22
      Replying to @Cjw450Cathy @KenZeroHarm and

      4/4 ‘Expert’ concludes cause=under-watering as only finding was soil a little dry. But later find out all plants from store sick/died- virus affecting whole batch, unlikely to survive. But had to look for cause, so found ‘cause’ to satisfy need for search... wrong cause blamed...

      1 reply 0 retweets 0 likes
    6. Cathy Welch‏ @Cjw450Cathy Oct 22
      Replying to @Cjw450Cathy @KenZeroHarm and

      Moral of story- if you go searching for a cause of error you will find a cause (human nature to justify the search), but once you find a cause, there is no need to look further, so the real contributing factors (and protectors that kept plant alive as long as did) are never seen

      1 reply 1 retweet 1 like
    7. Cathy Welch‏ @Cjw450Cathy Oct 22
      Replying to @Cjw450Cathy @KenZeroHarm and

      So, after the first investigation, it would be judged and labelled ‘avoidable’, but was it? Hence why I say ‘avoidable’ is a loose, subjective, and potentially harmful label

      3 replies 1 retweet 1 like
    8. Cathy Welch‏ @Cjw450Cathy Oct 22
      Replying to @Cjw450Cathy @KenZeroHarm and

      But also never going to get ‘Zero Avoidable Harm’ as long keep focussing on searches for ‘avoidable causes’- you will always find what you look for...’avoidable causes’. It’s a never-ending closed loop that never reaches its goal, and never really leads to improvement

      1 reply 0 retweets 0 likes
    9. Dr Gordon Caldwell‏ @doctorcaldwell Oct 22
      Replying to @Cjw450Cathy @KenZeroHarm and

      Two groups look at a set of notes, group A knowing the patient died, group B just asked to look for faults errors or substandard work. Group A reports twice as many faults as Group B. Knowing the outcome biases the observations.

      2 replies 0 retweets 9 likes
    10. Dr Gordon Caldwell‏ @doctorcaldwell Oct 22
      Replying to @doctorcaldwell @Cjw450Cathy and

      I was recently given a set of notes in relation to a complaint and decided to analyse the notes without first reading the complaint, so I might reduce this type of bias

      3 replies 0 retweets 1 like
      John Clarke‏ @C7RKY Oct 23
      Replying to @doctorcaldwell @Cjw450Cathy and

      It could be argued that by doing so, you merely serve to reinforce another bias though - the bias of a doctor. It must be ok, because I wouldn't have noticed it either? Air crash investigations may seek to understand why a mistake was made via that route, but doesn't dismiss it.

      1:33 AM - 23 Oct 2018
      1 reply 0 retweets 0 likes
        1. New conversation
        2. Cathy Welch‏ @Cjw450Cathy Oct 23
          Replying to @C7RKY @doctorcaldwell and

          I think Gordon’s point is to limit the bias at 1st steps. He would still need to see outcome before writing response, but it means he can objectively assess situation before adding influence of emotional response

          1 reply 0 retweets 0 likes
        3. John Clarke‏ @C7RKY Oct 23
          Replying to @Cjw450Cathy @doctorcaldwell and

          I disagree. I think that's arse about face. The most important thing in all this is to learn every possible lesson. If you approach as suggested, then even if later shown the outcome, a pure human reluctance to think ourselves wrong may lead to important issues being dismissed.

          2 replies 1 retweet 1 like
        4. Cathy Welch‏ @Cjw450Cathy Oct 23
          Replying to @C7RKY @doctorcaldwell and

          Perhaps both right, both wrong. But can spend all efforts trying to fix ‘wrongs’, while missing opportunities to understand why things go right much more often- I would rather spend time doing both, in balance, to maximise opportunities to get it right more often

          1 reply 0 retweets 0 likes
        5. Cathy Welch‏ @Cjw450Cathy Oct 23
          Replying to @Cjw450Cathy @C7RKY and

          And in reality, things sometimes have to go wrong to learn them. ‘Failure’ comes from inability to accept/acknowledge when things don’t work.

          2 replies 1 retweet 0 likes
        6. Cathy Welch‏ @Cjw450Cathy Oct 23
          Replying to @Cjw450Cathy @C7RKY and

          What has hurt far more people is not acknowledging things didn’t work as planned/expected, then making excuses to cover rather than facing up to reality

          1 reply 0 retweets 2 likes
        7. Cathy Welch‏ @Cjw450Cathy Oct 23
          Replying to @Cjw450Cathy @C7RKY and

          We live in a culture where error/failure is frowned upon, ridiculed. No wonder nobody wants to accept or openly acknowledge when something has gone wrong, when our society builds its image of respect and status on ‘success’ as defined by absence of failure.

          1 reply 0 retweets 0 likes
        8. John Clarke‏ @C7RKY Oct 23
          Replying to @Cjw450Cathy @doctorcaldwell and

          I don't know of a single complainant who has, or had, a belief that doctors should act with an 'absence of failure'. We're all human. We get that mistakes happen. But the cover ups are a different matter. You'll find a patient tolerance level of zero is pretty universal for that.

          2 replies 4 retweets 4 likes
        9. John Clarke‏ @C7RKY Oct 23
          Replying to @C7RKY @Cjw450Cathy and

          I can't speak for anyone else, but what I admire is not success as an absence of error, but those who demonstrate honest endeavour. With the emphasis on honest - at all times in a dr/pt (/relative) relationship. Respect is a futile expectation when candour is lacking, imho.

          1 reply 3 retweets 2 likes
        10. 5 more replies

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