The making of expert clinicians: reflective practice.

Debriefing is a rigorous reflection process which helps trainees recognize and resolve clinical and behavioral dilemmas raised by a clinical case. This approach emphasizes eliciting trainees'assumptions about the situation and their reasons for performing as they did (mental models). It analyses their impact on actions, to understand if it is necessary to maintain them or construct new ones that may lead to better performance in the future. It blends evidence and theory from education research, the social and cognitive sciences, and experience drawn from conducting and teaching debriefing to clinicians worldwide, on how to improve professional effectiveness through "reflective practice".

Design of high reliability organizations in health care.

To improve safety performance, many healthcare organizations have sought to emulate high reliability organizations from industries such as nuclear power, chemical processing, and military operations. We outline high reliability design principles for healthcare organizations including both the formal structures and the informal practices that complement those structures. A stage model of organizational structures and practices, moving from local autonomy to formal controls to open inquiry to deep self-understanding, is used to illustrate typical challenges and design possibilities at each stage. We suggest how organizations can use the concepts and examples presented to increase their capacity to self-design for safety and reliability.

Lessons learned from non-medical industries: root cause analysis as culture change at a chemical plant.

Root cause analysis was introduced to a chemical plant as a way of enhancing performance and safety, exemplified by the investigation of an explosion. The cultural legacy of the root cause learning intervention was embodied in managers' increased openness to new ideas, individuals' questioning attitude and disciplined thinking, and a root cause analysis process that provided continual opportunities to learn and improve. Lessons for health care are discussed, taking account of differences between the chemical and healthcare industries.