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.
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This isn't about 'fixing wrongs' for me. Some errors may be able to be corrected/minimised if honestly disclosed early on, (how I wish!), but so often medical harm is irreversible and beyond fixing. Particularly if the patient dies. This is about preventing reoccurrence.
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And in that regard, learning from what works should be a Janet & John management activity for me. (Showing my age). It's right that failures attract the greatest attention, as they do in any regulated environment, but there needs to be a clear picture of what 'right' looks like.
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And how ‘right’ usually happens (more often than ‘wrong’), including all the adjustments, connections, adaptations that people make with moment-moment variation to keep in the right direction towards success
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We could get lost down the rabbit hole of all that makes up what's 'right'. Key thing is to model the behaviour of the most effective staff. By external observers. Often the best people are unconscious competents. Meaning they don't always know why they're as good as they are.
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But we don’t explore that well, we don’t spend any energy trying to understand that, or actively promote that. We don’t invest in time, energy, resource to understand the subtleties of ‘good’, we just assume it’s there and look at the ‘bad’, with angry hearts and blinkered eyes
End of conversation
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