In 2017, the president of the United States in Psyverse #2 was thinking of establishing a “Space Force”. It was to be a new military branch that dealt with national defence matters in space. The president ordered a draft proposal to be sent to the head of NASA for revision.

Unfortunately, the official put in charge of writing said proposal had just recently had a child with their partner. The previous night had been spent attending to their cute, but extraordinarily loud, baby. In the official’s slightly delirious state, they misheard the orders of the president. They wrote a proposal about a new project codenamed “Space Horse” - a mission to send the first horse into space.1

At the time, the United States was competing with the British to achieve various space-related firsts. The head of NASA started asking colleagues about the feasibility of equine astronauts for a space horse race with the British. They quickly suggested he should probably see a psychiatrist.

So, when a man entered a relatively inexperienced psychiatrist’s office talking about the advantages of designing a space suit for a Mongolian horse instead of a Shetland pony, while also claiming to be the head of NASA, eyebrows were immediately raised.

Through quite a remarkable feat of pure bad luck, both parties managed to completely misunderstand what the other was saying. For instance, when the psychiatrist asked about any past feelings of stress, being wide-eyed or perhaps times he felt exposed, the head of NASA described the first time he tried to take a photo of the stars on the International Space Station “All I could see in front of me was darkness - a vast emptiness that extended beyond my imagination”.

The psychiatrist thought this was a sign of depression. In reality, the head of NASA was trying to communicate his frustration at being unable to correctly set the exposure and aperture settings on his camera.2

The head of NASA was prescribed a Selective Serotonin Reuptake Inhibitor (SSRI).3 The response to SSRIs (and antidepressants in general) is assumed to be highly variable.4 For instance, some people may report complete remission of their depressive symptoms, while others report an “emotional blunting”. Some may receive no benefit at all. There is a great deal of uncertainty surrounding treatment response. What we can be certain of, however, is that a person without depression5 isn’t going to benefit from the antidepressant effects of an antidepressant.

This does not mean that for the undepressed,6 taking an antidepressant is risk-free. SSRIs, particularly when it comes to various bedroom activities,7 can produce noticeable side effects. The head of NASA and a firefighter, who also happened to be his wife, both noticed these noticeable side effects. After six weeks, due to not noticing any noticeable improvement in his actually notably fine brain, the head of NASA booked another psychiatric appointment to discuss the matter, then made a note of the date in his calendar.

As the appointment was during work hours, the head of NASA arrived in his official jacket.8 It did not take long for the psychiatrist to realise that yes, this was in fact the head of NASA and yes, NASA was indeed trying to send a horse into space. It was agreed that it would probably be best if the head of NASA weaned off the SSRIs.9

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With that mistake dealt with, all that was left was this silly old horse thing. The head of NASA booked a meeting with the commander-in-chief. Now, if the United States had a president who could admit mistakes, everything would have gone back to normal. But the U.S. didn’t. And thus, the USA became the first country on Earth #2 to announce it was going to put a horse into space.

The British, rather predictably with their storied history of drawing galloping horses incorrectly,10 couldn’t let this stand. They announced that the U.S. was sadly mistaken. It would be the Brits that would be the first to put a horse into space! Australia, who couldn’t let some Poms get away with any horsey business, entered the race too – but with a kangaroo. It didn’t go well. Kangaroos like to kick.11

As news spread around the world, more nations with proud associations with horses entered the space race.12 Even Mongolia, despite their less-than-ideal technological situation, sprang into action. Hey, if Genghis Khan could conquer a quarter of the world in a quarter of a century on the back of a Mongolian horse,13 surely the great country of Mongolia could send one into space.

It became clear to the countries involved that the task of sending a horse into space was not going to be easy. Starting in all places, with their complicated digestive system. Annoyingly, horses need to feed almost all the time. Other than leaving little room for the many administrative tasks required of a horsetronaut, a lot of hay, grass, grains and fruits would be needed. If the horse were to stay for any protracted period in space, produce would need to be grown.

Fortunately, there exists an entire field of Astrobotany14 you probably didn’t know about until this sentence. Despite the problems of growing plants in space15 plenty have already been grown on space stations like the ISS, and even a cotton plant briefly grew on the far side of the moon. So interestingly, growing the steroid-infused grasses for a horsetronaut was the least of the Psyverse #2 countries’ concerns. What happened when the space horse swallowed the grass was the bigger issue.

Horses may have a problem digesting food in space. They rely significantly on enzymatic digestion. The massive caecum in a horse – around 30 litres – acts as a kind of fermentation vat, where bacteria and enzymes break down food. The entry and exit to the caecum are at the “top” of the horse. Gravity is required to keep food in the caecum to ferment, and the caecum uses peristalsis to move food up and out into the large intestine. It might be the case that there would be a greater chance of impaction in microgravity.16 Which would not be good for the short-term health of the horse.

On the other hand, bacteria thrive in space.17 Some strains seem to grow much more quickly, though it is unclear why.18 This might offset the gravity problem in the caecum.19 Nevertheless, the horse digestive system is incredibly fragile. One of the most common causes of death for a horse is colic,20 which is a catch-all term for the symptoms caused by over 70 different types of intestinal problems.21

For our intrepid nations of Psyverse #2, digestion is not the end of the story. If a horse is to spend any reasonable length of time in space (months), their musculoskeletal22 system will likely weaken significantly. For humans in our universe, we have found that microgravity reduces bone mineral density, decreases muscle mass, and loosens tendons.23 A horse in space would have a greater susceptibility to bone fractures24 and would be significantly weaker on return to Earth.

One potential solution would be to breed “Mighty horses”. By inhibiting genes that produce proteins involved in muscle and bone loss – myostatin and activin A – researchers Emily Germain-Lee and Se-Jin Lee showed it was possible to breed jacked mice.

They then sent the mice adonises with their normal counterparts to the International Space Station (ISS). The swole mice were protected against both muscle and bone loss in microgravity.25

Perhaps the most important factor that would need to be considered is the behaviour of the horse in microgravity. Weightlessness could be very disorientating for the equine astronaut. Fortunately, there is a 1995 paper by a Japanese researcher called S. Mori26 which definitely helps illustrate the postures of various mammals in microgravity:

According to this figure, I have scientifically deduced the most likely posture a horse would have in microgravity:

Interesting. Looks like we have horse drawing history all wrong. Artists weren’t drawing horses galloping; they were drawing horses in microgravity!

Despite an initial panicked and disoriented behaviour, there is some reason to believe that a horse would become acclimatised to microgravity. Mice are frequently sent up to the ISS, and after hanging around for a couple of days, they eventually learn to whizz around their cage as if it is one giant stationary wheel.27

The choice of breed is crucial for any space-faring horse. Thoroughbreds would be far too agitated to deal with the stressors of space, increasing the risk of conditions like colic. Ironically, one of the calmest breeds, the Clydesdale, is also one of the largest. In rocketry, the larger and heavier the capsule, the bigger the rocket needs to be, the higher the cost.

We are just touching the surface of the potential problems that would need to be solved to send a horse into space. There is potential for retinal damage, or cardiovascular insufficiency. If it is a long-term mission, you would have to think about horse breeding28 and radiation effects. How would a horse use the controls?29 What would you do with horse waste? If you wanted to do a space-trot, how would you get the horse into the spacesuit?

It took until the end of the 2020s for the United States to be finally ready to send a horse into space. The head of NASA had settled on an American Quarter Horse due to their calm temperament and highly trainable nature. The rocket was on the launchpad, the Quarter Horsetronaut had a calm and determined look in her eyes.

Then the head of NASA turned on the television. A Mongolian flag was painted on a spaceship orbiting around Earth #2. Inspired by the wooden satellite “LingoSat” launched in late 2024, and the wooden heat shields on the Fang Shi Weixing satellites developed by China in the 1960s,30 the Mongolians had built a wooden spaceship.

The head of NASA tilted his head to the right. Right there, proudly floating in the cockpit, legs splayed out, was a Mongolian horse.

After more than a decade of effort, the United States had lost the space horse race to Mongolia.31 In a wooden spaceship no less! Dejected, the head of NASA wondered why on earth (#2) they started this godforsaken project in the first place. Oh, wait, that’s right. A mistake. This whole project snowballed from a single mistake. Otherwise, the whole thing went pretty smoothly.

Not like that incident with the psychiatrist, the head of NASA thought. He seemed to make plenty of mistakes. In need of a distraction, the head of NASA revisited the psychiatrist who mistakenly gave him medication for a condition he didn’t have.

“Where did you anonymously report the mistake to?” The head of NASA asked out of curiosity. The psychiatrist gave him a confused look “What do you mean ‘anonymously report the mistake’?”

“You know, you fill out a little form, send it off to an independent national organisation, they do an investigation. That sorta thing” the head of NASA replied.

The psychiatrist paused in thought for a few seconds “Hmm. There isn’t something like that here… but I do recall something like that in a country in Asia. Ahh, it is on the tip of my tongue! Like, had that guy that conquered a whole bunch of places… Gengu… Gungis…”

“Oh god. Please no…” the head of NASA interjected “…is the country Mongolia?”

The psychiatrist’s face lit up. “Mongolia! That’s it! The Mongolian patient safety reporting system. I’ve heard it’s been quite successful. Even helped send that horse into space. Crazy world we live in!”

The head of NASA made a quiet whimper as his head sank into his neck. Without saying a word, he turned on his heels and slumped his way out the door. He knew that if he wanted to build a national patient safety reporting system in the United States, he would need to learn from the best.32 In a tone resembling Eeyore from Winnie the Pooh, he muttered “Why is it always Mongolia?”

The next day, he booked a flight to the country that he now disliked with all his heart.

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10

Before videos, people could not figure out how the legs moved on a horse in full gallop. Horses’ legs moved far too quickly. Therefore, there are a whole host of paintings where horses are seemingly levitating with both sets of legs outstretched.

Eadwaerd Muybridge, photographer and part-time alleged murderer, designed the first-ever cameras that could take images quickly enough to film a horse in a gallop without being blurred.

On June 15, 1878, he invited the press to see his process. He showed how he captured the images using trip wires and 12 quick-exposure cameras. This was the first ever moving picture.

It was not a good day for horse artists.

Historical Note: Before perspective was figured out, some medieval artists had an especially bad time drawing horses…

13

The rate of expansion of the Mongolian empire is truly astonishing.

32

I didn’t include the Psyverse #2 Mongolia story as I felt this was a natural ending to the article. I was going to say that Mongolia, due to their inexperience in building rockets, had a lot of injuries. This would bring the aviation engineers, pilots, etc., into hospitals. Thus, there would naturally be a conversation about the lack of incident reporting systems in healthcare.

Given that much of the population of Mongolia is highly concentrated in small areas (the capital Ulaanbaatar contains almost half the population of the country), with large geographical separation between these areas, this makes the logistics of setting up a reporting system much easier, I would guess. i.e. testing of procedures in towns with the same population, which can then be applied to large hospitals in the few big cities.

Subsequently, I was going to say the incident reporting system helped to improve safety, as well as improve the medical system generally. Psychiatry was a huge beneficiary. The significant problems with mental health that Mongolia faces started to be tackled. Combined with the technological scarcity, innovation increased dramatically, leading to the wooden spaceship.

All of which is ridiculously flawed, wishful thinking, to the extreme. But you have now learned more about Mongolia, a country not often talked about.

This is the final article in the Psyverse #2 series. For previous posts, see the compendium.

I try as much as humanly possible to find the nuance in every field I explore. I try as much as possible to see the bigger picture. When it comes to psychiatry’s own engagement with human error, however, there is no bigger picture. There is barely even a drop of paint on the patient safety canvas.

Yes, there are important, emotionally vulnerable stories about iatrogenic harm. There are bold debates about coercion and autonomy. There are discussions about involuntary commitment from both patient and clinician.

But, put bluntly, none of this translates into meaningful structural change. Patients continue to be harmed; operational safety still isn’t central to the field.

If it were, we’d see sustained, mainstream engagement with human factors, human error, and learning systems across flagship psychiatric outlets. Psychiatry would be heavily involved and integrated within the safety science field. Structures such as safety management systems, incident reporting systems and investigation bodies would be prevalent. Just like it is in aviation and, to a lesser extent, other fields in medicine.

Be honest, when was the last time you read a flagship psychiatric editorial centred on human error? That this still feels marginal in 2026 — more than twenty-five years after the patient safety revolution — is a serious failure of imagination.

When the subject of iatrogenic harm is discussed, we quite rightfully highlight the pain, the injustice and discuss the philosophical implications to the ends of the earth. But in the final analysis, I cannot help but conclude that few are willing to roll up their sleeves and venture into the subject of human error.

I believe this is psychiatry’s crux. In physics, when we need tools from another discipline, we go and learn them. Psychiatry appears more inclined to stay in its lane. While I understand this is beneficial and often necessary for everyday clinical practice, the result is psychiatric discourse has all the epistemic variety of a greyscale Rubik’s cube.

Where are the psychiatric innovators? Who speaks for systemic safety change in psychiatry?

Looking back through the history of aviation reporting systems, I could not help but notice the social push for better safety. Through their associations, pilots, air traffic controllers, and other aviation staff relentlessly advocated for better aviation safety systems. I do not see this kind of advocacy in psychiatry.

I have been impressed by the insight of authors tackling the complexity of psychiatry. I have been engaged learning about the hope, or indeed false hope, of new treatments. I have been moved by deeply personal stories of patients and practitioners in their struggles navigating the psychiatric system. I have had my mind changed through the continuous dialogue about what diagnosis is and isn’t.

And none of it matters.

Even if you came up with miracle treatments or technologies tomorrow that cured every single mental illness, even if you proved it was effective, it would not matter. Because you wouldn’t be able to convince patients to take it.

Someone has to design the treatments. Someone has to diagnose the patients. Someone has to administer the interventions. And with people comes human error. Patients would continue to be harmed, some would die.

When new technologies are introduced, people do not demand “better than before”. They demand near perfection. Trust is not built on promise. It is built on reliability. Without a rock-solid foundation of patient safety systems in psychiatry, none of the mountains of quality mental health commentary matters. Still, I wouldn’t even say the foundation of patient safety systems in psychiatry is flimsy. It has to exist first.

Building these systems requires a culture that treats error as data, not disgrace. In 2005, Justin Waring interviewed 28 specialist physicians about their attitudes to human error. Many described mistakes as inevitable – “Human error is always going to occur,” one said. Error reporting was widely regarded as pointless. If error cannot be eliminated, why report it?

How much have attitudes changed since? Does psychiatry, and perhaps healthcare in general, still focus on individual performance, over system safety?

I can’t know. What I do know is that having been a patient in the medical system for over a decade, I almost expect error to occur. I have to fight complacency. My psychiatrist, whom I respect, asks at every appointment whether I am still receiving rTMS treatment. I stopped five years ago. At some point in almost every year since my sister was born, my mum has to phone healthcare professionals to ensure my sister’s tube feed arrives on time. The very food my sister needs to live is not exempt from human error.

It doesn’t have to continue like this. Change is possible. The knowledge already exists. We do not need a new philosophy. We need to engage with the safety science already built.1

Psychiatry does not lack intelligence. It does not lack compassion. It lacks operational imagination.

And until that changes, patients will continue to be harmed – not because we failed to debate, but because we failed to build.

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Welcome to the Psychiatric Multiverse – where we take an idea from an area of life, and postulate if it could be useful in the psychiatric system.

Today, we are postulating how an effective reporting system could be constructed in a hypothetical alternate reality. To explore previous articles in the series, visit the compendium.

To help with the split between our universe and Psyverse #2:

Explanations will be in normal formatting.

While the story of Psyverse #2 will be in italics.

Late one evening, I had an absurd idea.

While tucking into a good book, in the form of Don Norman’s The Design of Everyday Things, I read this paragraph about NASA’s role as the independent administrator of the Aviation Safety Reporting System (ASRS):

NASA is a neutral body, charged with enhancing aviation safety, but has no oversight authority, which helped gain the trust of pilots. There is no comparable institution in medicine (emphasis added by me)

I felt an excitement start to build – the kind that always accompanies me before a quest into the academic literature. “What if healthcare professionals just reported their mistakes to NASA?” I thought, as I leapt into my office chair and turned on my computer.

To my dismay, I was three decades late to the party. The U.S. Department of Veterans Affairs (VA) had the exact same idea while convening several expert advisory panels in 1997. After a talk by Linda Connell, the director of the ASRS, the VA enquired about the feasibility of applying an ASRS-like system to medicine. Both organisations worked together to set up what became known as the Patient Safety Reporting System (PSRS) in 2000.

The PSRS was run by NASA in a very similar way to the ASRS – it was an external, voluntary, confidential reporting system. There was, however, one major difference. It was run as a complementary system to the VA’s own internal one with the same coverage. PSRS was intended as a “safety valve” for reporters who wanted confidentiality. Unfortunately, unlike the ASRS, it was not successful. Over a 10-year period only 500 reports were submitted to the PSRS, while the internal VA system received approximately 700,000.

Due to cost-cutting measures, the partnership between NASA and the VA ultimately ended,1 leaving only an abandoned website as a window to the late 2000’s internet.

Ever the optimist, and lover of left-field ideas, I was not discouraged by this failure. I read more about incident reporting, going far deeper into the subject than I had anticipated.2 I think there is a genuine need for improved patient safety incident reporting systems. But how could it be done?

Fortunately, here at the Psychiatric Multiverse, we don’t have to worry about the frustrating roadblocks of societal and political forces. All we have to do is imagine our universe splitting in two at this very moment. One continues as our own universe, the other (Psyverse #2) builds a national patient safety incident reporting system in the United States.

Using what we have learned from the history of aviation reporting systems, and the current literature on patient safety reporting systems, let us try to figure out how an incident reporting system could be built.

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Patients, Patients, Patients!

Firstly, I believe a truly effective patient safety reporting system has patients reporting incidents. Patients are the ones with the most skin in the game. They are the ones harmed by mistakes. They are front and centre in the discussion about their care, and if they have the mental capacity, they have a veto over any treatment proposed.

In aviation reporting systems, both air traffic controllers (ATC) and pilots report incidents.3 Drawing an analogy to medicine, doctors are like air traffic controllers, and patients are passengers who are suddenly thrust into becoming pilots. While patients generally know little about their bodies, ultimately, they are the ones who have to “fly the plane”, so to speak. Therefore, patients see a very different picture compared to the “ATC” doctors, who can only advise and provide treatment.

Logically, it follows that a patient’s perspective is essential to fully understanding an incident. Information from patients can be useful in isolation, but the primary value comes from the added incident context through doctor-patient report comparison. But, with our current patient safety reporting systems, many don’t even allow for patients to report, while for the ones that do, they make up a tiny proportion of incidents. Which begs the question: how can we expect patient safety reporting systems to help indicate where system wide learning can take place, if we are missing information from half the system?

Including patients in an incident reporting system would not be as straightforward as simply allowing them to fill in forms. Factors like the design of the report form,4 legal protections,5 promotion of the reporting system to patients6 and feedback mechanisms7 would need to be addressed.

Starting our story of Psyverse #2:

Due to wildly improbable circumstances,8 a sudden social and political will to build a national patient safety incident reporting system within the United States #2 arises. Miraculously, the U.S. #2 government in this alternative world takes this public pressure as a sign they need to do something.

To figure out how to design an inclusive reporting system, they create the Never Again Unit (or NAU – pronounced “now”) to consult with patients and lived experience experts.9

They help design a form with plain English language, simplified to the digital equivalent of one side of A4 paper. The form has only very basic fixed-choice questions to ascertain where the event took place, with the free text portion dominating (prompts a simple question: what happened?). They find in testing that the “callback”, where patients are called back for clarifications, is essential with patient reporting. It not only ensures that the lived experience analyst correctly understands what occurred but also provides an excellent opportunity to indirectly promote the system.

Every stage of the reporting process has patient and public involvement. Working with their clinical counterparts, lived experience analysts help to decipher patient narratives, while lived experience investigators help to spot areas of improvement (that may otherwise be missed from a clinical perspective).10

The government drafts specific legislation to protect the patient incident reports from being used as evidence in legal proceedings (reports are privileged). Patients are asked to be involved in investigations through the confidential communications software. Later, promotion of the program is integrated into the wider strategy, when NAU teams up with the promotions team at the yet-to-be-announced independent third party.11

A trusted third party

In a previous article, we argued that there is a need for national patient safety reporting systems. This is especially relevant for the United States, which currently doesn’t have one - instead relying on a complex fragmented web of voluntary institutional reporting systems conglomerated into one national database. Briefly, health care providers can report to a Patient Safety Organisation (PSO), which can then send a standardised report to the Network of Patient Safety Databases (NPSD).12

While healthcare providers have found some benefit in reporting to PSOs, significant difficulties remain, including low participation, legal protection confusion, and poor patient involvement.13

It may be best, therefore, to start afresh. But given the importance of an independent third party, which one would be best? The architects of the ASRS emphasised that “not any third party” will do. From the NASA Reference Publication on the ASRS:

Any organization called upon to manage and direct a program as sensitive as ASRS has proved to be must meet several criteria, among which are the following: ( 1 ) credibility with users, the relevant community, and the bureaucracy; (2) unquestioned integrity; (3) experience in gathering and handling information; (4) technical proficiency; and (5) an understanding of the community, the operational context and an appreciation of the relevant political issues.

Currently, the Agency for Healthcare Research and Quality (AHRQ) runs the Network of Patient Safety Databases. Given the institution’s non-punitive function, combined with previous experience handling technical information and a deep understanding of healthcare, the AHRQ would seem like the perfect third-party.

There is, however, one major problem. Very few people outside of the U.S. healthcare professional community (i.e. patients) know about the AHRQ.14 Any third party must at least be known by patients, never mind have credibility with them, if we want patients to report. Ten years ago, the Centers for Disease Control and Prevention (CDC) may have been a better bet, given it is more widely known and has experience in dealing with large healthcare datasets. But the CDC doesn’t, erm, have the best reputation with the public at the moment.

Thinking about it, not many U.S. institutions seem to be seen in the greatest of lights right now – from both sides of the political spectrum. I think NASA is probably one of the few institutions that has the name recognition, is still widely thought of as credible, capable and independent, while also having the relevant technical proficiency.15 It has run the successful ASRS and must have learned lessons from the failed VA-PSRS project.

But, for any independent third party chosen to run a hypothetical United States national patient safety incident reporting system, the historical roadblock of healthcare staff not reporting to the old VA-PSRS system needs to be addressed. Perhaps there is an out of the box solution.

Continuing the Psyverse #2 story:

Popularised in the media as “The Decision”, the actual selection of an independent third party was relatively straightforward. Many stakeholders argued for over a month about why they were best placed to run a national reporting system, then it was awarded to NASA.16 Ultimately, there was no way of competing with the reputational capital that comes with successfully launching a horse into space.17

A Prototype in Psychiatry?

Both Charles Billings and Lucian Leape expressed concerns that the complexity of the medical system would forbid useful functioning of a national reporting system in the United States. However, Billings, in his 1998 talk to the National Patient Safety Foundation, proposed a possible way forward18:

I would offer you some hope that it may be possible to define areas within medicine in which there is a somewhat smaller constituency, a somewhat smaller group of stakeholders and within which, therefore, the problem may be slightly more tractable than it will be if you decide that your purview is all of medicine. I am not sure I would know at this point, even after 20-plus years of experience with this business, how to design a system for medicine. I think I could perhaps design a system for some subsegments of medicine, that are more tightly circumscribed, but I hasten to add that I am not even sure of that.

I would put forward that the psychiatric system is one of the better places to begin building a national reporting system.

Historically, psychiatry was somewhat separated from general medicine – both conceptually and geographically (in the form of asylums). While there has been a growing effort to integrate mental and physical healthcare systems, divisions remain.19 Oddly, while this separation likely hinders the current quality of care of patients, it arguably reduces the complexity of implementing a reporting system.

In an inpatient setting, the reduced interaction with general medicine means fewer types of health practitioners involved in incidents. Potential investigations may initially stay within the confines of a psychiatric ward (or within a separate hospital entirely). In an outpatient setting, most interactions between a psychiatrist and patient involve only a conversation.

The technological simplicity of psychiatry also lends itself to easier reporting system implementation. It is impossible to report an error with a complex diagnostic test if they don’t exist. In many cases, the most advanced diagnostic technology used in a psychiatric clinical setting is a piece of paper.20 Treatment of mental health conditions remains mostly confined to therapeutic methods or medication, though there is a growing use of brain stimulation methods.

The relational complexity of psychiatry, spanning issues like coercion, capacity, stigma and broader ethical issues, makes the narrative-rich free-text section of incident reports particularly valuable. A lot could be learned and improved upon using the narratives of psychiatric patients and staff.

While many types of patient safety factors are shared with general medicine,21 some are relatively unique. On the patient side of things, there is likely little that indicates a need for improved psychiatric patient safety (and care) more than an entire anti-psychiatry movement. Also, self-harm and suicide are increased risk factors. On the healthcare worker side of things, the potential for aggressive behaviour (in certain settings of some sub-groups of patients) means that not only are physical injuries more likely, but healthcare professionals can also often suffer mental harm through second victim syndrome.22 After investigation, some system wide changes may also be unique. For example, changing décor and introducing physical barriers may lead to safer environments.

Perhaps the best argument for implementing a national incident reporting system in psychiatry is that the field has the most to gain from a focus on patient safety. Up until now, the field has mostly been “in a world of its own”. Psychiatric patients were either excluded or not mentioned in landmark patient safety studies or reports, while the psychiatric patient safety literature generally runs in parallel, rather than with, general patient safety literature. Psychiatric safety remains an under-researched field.23

A team at NASA #2 assembled to plan and implement the new national reporting system. They chose psychiatry as the field to test a prototype: the Psychiatric Safety Reporting System. The NASA team batted away suggestions that the subsequent acronym, PSRS, would be “confusing” compared to the previous PSRS,24 since that PSRS was too old to be of relevance to this PSRS. The name stuck regardless.

Rather than relitigate a very complex US #2 incident reporting landscape, NASA #2 sets up a new Patient Safety Organisation that covers all of the psychiatric system. They have their own database and run their own analysis. Over the 5-year testing period, they iterate the design of the report form, developing their own standardised taxonomy of incidents. However, throughout this period, the analysts still convert a copy of the incident submissions to common formats and send it to AHRQ and the Network of Patient Safety Databases.

The NASA #2 team finally sets up a national investigation unit called INSIGHT (Independent National Safety Investigation Group for Healthcare Transformation). It is modelled after HSSIB in the UK.25

If successful, the PSRS program will be slowly applied to other medical fields, replacing the AHRQ program. It is proposed the name would then be changed to the Patient Safety Reporting System, or PSRS for short.

Open databases

Right now, you can go to the Aviation Safety Reporting System website and look through any report that has ever been submitted to the ASRS. It is completely open to the public. No need to sign up. No special clearance required.

The open ASRS reports include both the fixed choice and narrative sections, with a very short synopsis at the end. There are report sets grouping reports together by type of incident. They contain synopses and narratives. There is not a statistic in sight.

Compare this with the UK’s Learning From Patient Safety Events database, and you get a very different story. Only health and social care staff have access to the patient safety incident reports,26 seemingly restricted to reports from their own local organisation. The only public data available consists of purely summary statistics.

It is a similar story in the United States. For instance, the FDA Adverse Event Reporting System (FAERS) also doesn’t include the narrative portion of the report in the quarterly data files or public dashboard (which again shows only summary statistics).27 The AHRQ Network of Patient Safety Databases page has chart books, dashboards and spotlights – all showing summary statistics, with no hint of a narrative section or synopsis in sight.

The medical system’s obsession with statistics in patient safety reporting is confusing, to say the least. The predominant value of incident reports resides in the narrative (qualitative) data, not the fixed-choice quantitative part. Therefore, the patient safety database statistics are of little practical use.28 They also do not seem to change much from quarter to quarter, providing little to no new information.29

In order to have an open database, the incident data would need to be deidentified. It has always confused me why so little anonymised medical data is accessible in open databases. I would argue that the benefits of allowing access to anonymous medical data far outweigh the very small risk of reidentification.30

With narrative sections in patient safety reporting systems closed off from the public (and possibly other healthcare providers where the incidents didn’t occur), local healthcare providers who conduct their own root cause investigations lose opportunities to achieve a wider “window into the system”. Access to multiple perspectives of slightly different incident reports from other providers offers helpful context for investigation. An open database would also increase the likelihood of communication and collaboration between providers - duplication of root cause analysis investigations would become less likely.31

Access to incident reports across a country can help enormously in equalling the power imbalance between a patient and practitioner (and subsequent practitioner learning). For example, would the historically widespread dismissal of patients with Chronic Fatigue Syndrome (CFS) be so widespread if CFS patients could show their doctor incidents (or even better: root cause investigations) of similar adverse outcomes?

The PSRS team at NASA #2 sets up both a private and a public database. They add an “opt-in” tick-box asking the reporter if they would like to include their deanonymised report in the public open database. The private database contains all reports, and the public one has opt-in reports (including full narrative) with carefully worded synopses for opt-out reports.

A working group of patients, clinicians, data engineers, legal scholars and other experts is set up with the aim of determining the kinds of free-text data that should be modified or completely excluded when deidentifying report data. It is an ongoing process. Legislation is also written to protect patients and practitioners in any case of reidentification.

Promotion and Feedback

When my (then) psychiatrist produced a report with factual inaccuracies based on a 15-minute conversation about a simple dose increase of lithium, I contacted the Patient Advice and Liaison Service (PALS) asking for advice. During the two or three conversations I had with the PALS team, not once was it mentioned that it was possible for me to submit an incident report to the National Reporting and Learning System (NRLS), operational at the time (the NRLS was the predecessor to LFPSE).

In fact, the only reason I know about incident reporting systems at all is because I read about them in the aforementioned book by Don Norman. I would not be surprised if I were one of maybe five patients in the UK who know about the LFPSE incident reporting system.32 Gosh, by reading my series of articles on the subject, this may be the first time you, the reader, have even heard about the existence of patient safety reporting systems!

This is a huge publicity problem – especially because criticism of patient safety reporting systems is growing. As we discovered in the fourth Thin Line article about the ASRS, persistent promotion was critical for the program’s success. It is difficult to persuade diverse groups of stakeholders that a reporting program is useful if too few of them know about it, never mind report to it.33

When Charles Billings and Rex Hardy (of the ASRS team) introduced the first edition of CALLBACK magazine back in the 1970s, some of their NASA colleagues thought it was “shockingly casual for what was unquestionably a government publication”. But it was a successful strategy for reaching a wider, more diverse aviation audience.

In comparison, the UK’s LFPSE promotional material seems to consist of a webpage with a YouTube video and five unconnected podcast episodes, which makes for, erm, not exactly thrilling listening. The situation seems to be similar for the U.S. and the Network of Patient Safety Databases, with only a webpage (which includes a sign-up for email updates).34

Perhaps future promotion of patient safety reporting systems can learn from the casualness of CALLBACK. In the modern media age, the public and medical professional community are more accessible than ever. Why not produce short TikTok explainers, YouTube interviews or a Substack case study publication?35

This kind of promotion also acts as a feedback mechanism – a general audience is learning about the system. Reciprocally, feedback in the form of reporter follow ups (i.e. callbacks) helps to breed a sense of familiarity and trust with the people running the reporting system.36 Given many reporters in medicine currently feel like their reports disappear “into the ether”, the introduction of more rigorous feedback mechanisms appears greatly needed.37

The Psychiatric Safety Reporting System team at NASA #2 begins a targeted promotion strategy. Posters (both paper & digital) are sent to be put up where psychiatrist and mental health patient congregation is highest: Community mental health centres, psychiatric clinics, inpatient hospitals, pharmacies, etc. Automated messages are recorded for telephone queues. An “opt-in” tick box is added to patient complaints report forms all over the country, asking if they would like to include their complaint in the new learning system (an analyst converts the various complaint formats into the standardised form).

A publication and podcast titled “The Near Miss Clinic” launches for a general audience (including healthcare staff). Every month, a case study of a near miss, the subsequent report, investigation and improvement is followed. This is made possible through the open database. A YouTube and TikTok educational channel called “Psychiatry Safety Lab” is created. Every week, a different concept about patient safety in psychiatry is explained. There is an emphasis on an engaging, storytelling style to ground the message in everyday experience.

To engage a clinical audience, guest posts are regularly written on psychiatric-centred publications (like Psychiatry at the Margins, Psychiatric Times, RC Psych Insight, etc.), and interviews on podcasts and YouTube channels are booked. In the Psychiatric Times, a column about learnings from incident reporting in psychiatry is introduced.

After submission of a report, regular feedback on the course of the investigative process was facilitated through the confidential communication platform.38

The vital provision of transactional immunity

In the summer of 2020, I had to wait 42 days for lithium to be prescribed. There was nothing wrong with any of my blood or ECG tests. The psychiatrist who suggested lithium was experienced, a professor, even.

With every other medication I trialled, the time between agreement with my psychiatrist and prescription only took a few days (at most). So why, in the case of lithium, was there such a long delay?

Well, my psychiatrist professor was in charge of an rTMS centre, and I was receiving private treatment specifically for rTMS. He wasn’t allowed to prescribe me lithium, so I had to go to my local NHS centre. Long story short, the whole matter was eventually settled around day 40 of the 42 days, through communication between my local NHS psychiatrist and my private rTMS psychiatrist.

The first 40 days were filled with an unnecessary assessment, countless clinician group meetings, administrative mishaps and a fruitless communication with an in-house rTMS psychiatrist (not the professor). This, it could be argued, was an example of “active defensive medicine” – where more procedures were undertaken than needed for my care.39

The practice of defensive medicine, both passive and active, is highly prevalent throughout the world.40 While there are many good reasons to define defensive medicine broadly, the term is usually defined as physicians deviating from sound medical practice due to liability claims and lawsuits.

Within this culture of defensive medicine, it may be surprising to learn that the vast majority of patient safety incident reporting systems do not utilise limited transactional immunity (protection of the reporter from disciplinary action)41 – the vital provision that gave aviation professionals the confidence to report to the ASRS. Even the Department of Veterans Affairs PSRS, based on the ASRS, didn’t have transactional immunity.

Instead, the focus has been on providing privilege (protection of reports from being used as evidence in legal or disciplinary proceedings) and anonymity. Yet, one of the most significant barriers to reporting in medicine remains fear of reprisal. Why haven’t the privilege and anonymity protections removed this fear? And why hasn’t transactional immunity been introduced?

A potential explanation for the first question is provided by Huynh et al. (2017). The authors point out that healthcare professionals have a duty of candour – an ethical duty to be open and honest when an error occurs – codified by professional regulatory bodies.42 Given the privilege and anonymity protections usually only apply to the incident report they submit, a healthcare professional cannot remain truly anonymous. In fact, these types of protections incentivise not telling the patient about errors, then submitting a report - thus promoting unethical practice, an unjust culture and a continued fear of reprisal.

As for the answer to why transactional immunity is so rare in patient safety reporting systems, it appears partly due to the complexity of the healthcare regulatory system, and, at least in my opinion, partly due to a lack of will.

Unlike aviation, which typically has one national regulator, in medicine, there are multiple bodies for collections of professions within the healthcare system. In the United States, regulatory power is split even further into individual state regulators.43 Trying to produce legislation for immunity that all regulators will agree on is a tough task, to say the least. However, there is evidence to suggest the task isn’t impossible. Many states have enacted laws that provide immunity from civil malpractice claims for reports by physicians to the Department of Motor Vehicles (DMV) about patients who decide to drive despite being impaired by a medical condition. A similar kind of malpractice protection was advocated for at the beginning of the COVID-19 pandemic, when healthcare services were stretched thin.44

In terms of incident reporting systems, there have been a very small number of academic papers that have advocated for transactional immunity.45 But discourse remains thin on the ground. I find this lack of will confusing.

I can appreciate that the medical system is much more complicated than the aviation system;46 nevertheless, I am struggling to understand why transactional immunity cannot be offered for incidents which clearly do not cause harm to a patient.47 Malpractice claims cannot be filed for these incidents, and potential disciplinary measures would most likely be on the milder side.

With the backing of all state boards, U.S. Government #2 introduces legislation that provides transactional immunity for psychiatrists in possession of a receipt related to a no-harm incident submitted to the PSRS (within 10 days of said incident). Transactional immunity is limited to non-criminal, unintentional, and/or inadvertent actions. Immunity is also limited to one “usage” per type of no-harm incident, up to a total of ten types of incidents over a five-year period. Investigations can still be carried out. The immunity only waives sanctions. Funding is allocated to each state board to set up committees to settle any disputes.

A wider transactional immunity that includes harmed patients is planned if the PSRS is successful. It is recognised that implementation requires an overhaul of federal & state regulations as well as tort law.48

Harnessing technology

It is often mentioned that a major limitation of anonymous reporting systems is that two-way communication with the reporter is not possible.49 But this is no longer true. Two-way anonymous communication technologies exist and have existed for at least a couple of decades.

While there are different methods used to anonymise communication, generally, anonymity is preserved through the generation of a unique “key” (instead of any personal information) after the initial message by a reporter. This key can then be used to log in to a secure online platform.50

Most two-way anonymous systems have been used for whistleblowing or behaviour-related reporting (like bullying and harassment). Examples include: The Guardian newspaper’s SecureDrop whistleblowing service (launched in 2014), tip411 for anonymous tipping, and Whispli.

Anonymous communication is not restricted to text. There are ways to protect the identity of an individual in audio and video communication too. Both the metadata and speech data (i.e. voice) of calls can be anonymised.51 Currently, there is a wide range of use cases.

Despite anonymisation technology’s clear use case for follow-up and feedback in anonymous patient safety reporting systems, I could only find one paper mentioning two-way anonymous communication. A single sentence in a 2025 paper by Beecham et al.52 So far, all the anonymous patient safety reporting systems I have come across have been one-way.

Oddly, two-way anonymous communication systems are used within the UK healthcare system, just not for patient safety incident reporting. Perhaps the example closest to a patient safety reporting system is the anonymous two-way system set up by Moorfields eye hospital as a response to the Lucy Letby case. The system appears to be primarily focused on whistleblowing, but patient safety incident reporting is mentioned in the response.53

Anonymous communication is not the only software from other fields which could be used to improve the functioning of incident reporting systems.

Sometimes, when I’m looking through a forum trying to find out how to fix an open-source software problem (otherwise known as a “bug”), I will see a “duplicate” tag (e.g. see this thread on GitHub). This tag will link to a thread posted at an earlier date where essentially the same problem is discussed, and a solution found (Note: by “duplicate” I don’t mean identical. I am referring to a similar report by another person about the same bug).

In the open-source community, duplication detection is usually carried out manually (by the owner of the software). But in the commercial software industry, with large userbases and mammoth numbers of issues, automatic (or semi-automatic) triage and deduplication are often used.54

Duplicate detection algorithms automatically analyse the narratives and structured fields of bug reports, and flag ones which seem to describe the same bug.55

In incident reporting systems, duplications – reports about very similar incidents – have been shown to exist.56 Yet research on deduplication techniques for reporting systems seems to have only focused on one: the FDA’s Adverse Event Reporting System (FAERS).57

In both the bug and FAERS deduplication discourse, duplication is generally viewed as a problem – duplications are something to remove. However, there is evidence to suggest that duplication could actually be helpful. A survey conducted by Bettenberg et al. (2008) found that bug duplicates provided software developers with extra contextual information, helping to fix bugs more quickly. They advocate for merging bugs. There are parallels with the change of ASRS transactional immunity policy in the battle for immunity of the late 1970s. The extra context provided by each aviation professional submitting their own report to gain immunity for the same incident helped with investigations.58

Instead of seeing overreporting as a problem, deduplication software could add rich contextual information about very similar patient safety incidents, while at the same time reducing the workload of analysts.

Any deduplication software would need to utilise Natural Language Processing (NLP) of the free text portion of the reports. Here (and with machine learning in general), the literature on incident reporting is much denser, focusing primarily on automatic incident classification and event detection.59

By harnessing technology, the PSRS distinguishes itself from all previous predecessor reporting systems. Because reporters are given transactional immunity for non-harm incidents only, the team decides to build an anonymous communication feedback system called TRUST (Two-way Reporting for Understanding Systems & Trends). Reporters can anonymously submit reports via text or through an interactive voice response system.60

At the same time, NASA #2 partners with a large software company to build an incident report clustering system that will recognise very similar incident reports through free text NLP. Once finished and tested, it is integrated into TRUST.

The process of reporting goes as follows:

Upon submission of an incident report to TRUST, a psychiatric healthcare worker or patient is provided with a unique anonymous login key and confirmation that the report has been received. Before an analyst at PSRS #2 receives the submission, the clustering software searches for a similar case file in the database.61 Depending on what the clustering software finds, the process splits into three potential courses of action, described in this footnote.62

In all three courses of action, the original reporter is part of the process.

Integrated into a wider safety structure (both nationally and globally)

In the 2004 paper, When will healthcare pass the orange-wire test, Sir Liam Donaldson wrote:

Imagine that an airline engineer doing a preflight inspection [of a Boeing 757] spotted [an orange wire] frayed in a way that suggested a systematic fault rather than routine wear and tear. Imagine what would happen next. It is likely that most 757 engines in the world would be inspected—probably within days—and the orange wire, if faulty, renewed.

Like airlines, hospitals take charge of people’s lives many times a day. Yet, health care has lagged behind other industries in putting safety first in dealing with its consumers. A systematic fault that put patients’ lives at risk discovered in one country would not surely be rapidly and simultaneously corrected by health services across the world.

Over 20 years later, I think it would be fair to say we are no nearer to passing the orange wire test in healthcare. Why? Why has there been so little progress?

Part of the answer is explained by Carl Macrae, the researcher whose work I was most influenced by when writing this series of articles. In his 2025 paper Systematizing Safety, he writes:

One of the most striking features of the past few decades of effort to improve patient safety is the isolated and individuated character of much of this work: the field has blossomed with separate interventions, stand-alone programmes, discrete processes, individual roles, and distinct policies. This blooming of a thousand flowers across the field is indicative of the creativity and experimentalism that has been brought to bear on the problem of patient safety. But it is also indicative of something much more troublesome: fragmentation […].

At best, the management and organization of patient safety tends to consist of loose coalitions of projects and activities brought together under broad thematic priorities coordinated by a handful of highly-motivated (but often under-resourced) enthusiasts. At worst, it is a tragic mess.

Aviation incident reporting systems had the benefit of growing out of an already developed safety system, strongly connected throughout the entire world. This is simply not the case in medicine.

How do you build an effective national incident reporting system? The answer is you can’t. Not on its own. You need to build the entire worldwide patient safety infrastructure along with it.

Perhaps a start would be the setting up of an organisation like the International Confidential Aviation Safety Systems (ICASS) Group, which provides advice, facilitates the exchange of safety information and identifies solutions to common problems between different countries. Given the World Health Organisation is an independent worldwide body, I think it would be one of the prime candidates to advise countries on how to develop safety management systems, and then helping to connect these systems.63

Forget landing on the moon, or sending a horse into space, the greatest human achievement of our age may very well be building a worldwide patient safety infrastructure that passes the orange wire test.

After a decade-long development within the US #2 psychiatric system, Congress agreed that the PSRS should be expanded to every field in medicine, as part of a broader plan to implement a national patient safety management system. Sitting around the desk of the main meeting room, clothes untucked, bags under eyes and hair slightly dishevelled, the staff at NASA #2 took stock of what they had achieved, and what was to come. “This is only just the beginning, isn’t it…” one member groaned. “Yes. Unfortunately, yes” another half-heartedly responded.

The head of NASA #2, twiddling his thumbs, commented through half a grin “To think… all this happened because every country in the world decided to send a horse into space.”

Epilogue: the invisible boundaries between worlds

In 1989, Lucian Leape, fresh from learning that there were potentially 120,000 preventable patient deaths in the United States, decided he was going to learn as much as he could about error management in medicine. He strode into the Countway Library at Harvard Medical School and searched the archive for medical literature on mistakes. He found nothing.

Confused and slightly downbeat, he asked the librarian for help in his search. She thought the search strategy was fine, but recommended looking in the social sciences or engineering literature. When they searched this archive, hundreds of references came up. Many people in these disciplines already knew a lot about mistakes and how to prevent them. Lucian suddenly had a lot of reading to do.64

You and I live in a world of invisible boundaries. Problems that have plagued an industry for decades will have solutions sitting in an adjacent one. We frequently pass people from these parallel fields on the street, we chat to some of them, and a few will even be friends. But the gaps between subcultures mean that some of these people exist in industries with solutions lightyears ahead of others, in one very specific area. And no one notices.

What would happen if we merged these adjacent fields? What if human factors culture became embedded throughout the medical system? What if all the lessons from aviation reporting systems were successfully adapted to the psychiatric system?

What if psychiatrists reported all their mistakes to NASA?

And Breathe. Congratulations gang, we’ve made it to the end! Gosh, that was a long article, even by my standards… Thank you ever so much for reading this series - whether you stuck around for the whole shebang, or just popped by, I am grateful you’ve decided to read my work.

As ever, if you Alex is go for launch enjoyed the… T minus 10 seconds and counting …wait a minute… 9 did she just say I was “go for launch?” 8 Am I in a rocket launch? 7 that would explain why my desk is facing directly upward… 6 …and my desk is actually a control panel… 5 …and I’m in a space suit… 4, main engine start Main engine unstart! Main engine unstart! 3 Can someone please blow on the exhaust flames? 2 Ah well, might as well accept my fate. 1 Where am I going anyway? And we have liftoff! For Alex on his one-way mission to Mars! Mars? Awesome! Ha ha suck it Elon! … … … Did she say “one-way mission”?

If you enjoyed this article, please do drop a heart❤️, restack 🔄 or share 🔗. It helps others find my work!

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40

Passive defensive medicine describes avoidance behaviours (e.g. avoiding high risk surgeries).

A 2023 systematic review by Zheng et al. (2023) put the worldwide average percentage of physicians who engaged in defensive behaviours (both passive and active) at 75.8%.

For an introduction to defensive medicine, personally, I found the 2017 paper by Leonard Berlin very readable.

The reasons physicians practice defensive medicine are summarised in Kakemam et al. (2017, while psychiatry-specific reasons are explored in Scognamiglio and Morena (2025).

This is article 9 in the Psyverse #2 series (and article 5 in the Thin line series). For previous articles, see the compendium.

Paradoxically, perhaps the most thrilling aspect of literature review is also the most infuriating. I had to re-write this post twice after discovering articles and books that retold the history of patient safety incident reporting systems. The frustration of rewriting an article, however, pales in comparison to the joy of being able to tell a story that is not often told.

So, I hope you will enjoy this story about trailblazing nurses, an accidental anaesthesiologist, the malpractice insurance crisis and a Leape into the unknown.

A genesis in medication errors

Nurses are the unsung heroes of patient safety history, with significant contributions extending back to at least the early 1900s. The history of incident reporting systems is no different. As early as 1939, a professor of medical nursing named Margene Faddis proposed the recording of medication errors to prevent future mistakes from occurring:

[A] record, written by the nurse, is desirable. This is not a means of punishment but assures the appreciation of the importance of mistakes and also serves as future reference; it should include a statement of the notification of the doctor and full details concerning the error. Finally, let us remember that the ordinarily careful and conscientious nurse who makes the mistake has had, in the realization of her act, all the punishment and discipline and suffering which are desirable. What is done beyond that must be of a constructive nature or it had better be left undone.1

In 1953, Anne Byrne2 conducted a study that used a form to catalogue medication errors by nursing students. Through analysis of the data, Byrne found “wrong medication given” was the most frequent error and determined:

…that the nurse in charge was at fault in approximately 50% (11 in 20) of the instances, either because she did not transcribe the doctor’s orders correctly or did not make out the medication card properly.

The data was reviewed by a curriculum committee, and recommendations were made.3 A second study was then carried out shortly after, which found that the number of errors had been cut in half.

Two years after Anne Byrne’s paper, Catherine Corcoran published a master’s thesis with one of the first examples of an incident report for medicine: the “Unusual Occurrence Report”. The very simple open-ended form was used to collect evidence of medication errors by nursing students over the course of two years.4

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OOPSie-daisy

Possibly because of the early work on medication error incident reporting by nurses, the Board of Trustees at the American Hospital Association pushed for the establishment of full incident reporting systems back in 1958.5 It may have been one of the first report forms focused on incidents beyond medication errors. Quite what the result of this attempt was, I’m not sure. I could not find a record of what happened next.6

In 1962, Kenneth Barker and Warren McConnell published a paper looking at the problem of detecting medication errors. Previous publications had established factors which prevented reporting of errors, such as fear of recompense.7 But the best method to overcome these detection inhibiting factors had not yet been established.8

Barker and McConnell tested three methods of collecting information: disguised observation, self-report and the study of existing records. They showed through comparison between the hospital’s records and observation that there was a severe underreporting problem.9 It seemed like the authors were hoping that the anonymous self-report “OOPS” form (One Object – Patient Safety) would be a way of addressing this problem.

The OOPS report was the earliest anonymous reporting form I was able to find in medicine. The form was very simple, providing only a section to write a story. Unfortunately, the authors received just six OOPS reports in seven months. In Barker and McConnell’s opinion, this was because of several methodological flaws.10 Despite the issues, research into the detection of medication errors pivoted away from voluntary incident reporting to observation.11 The story of healthcare incident reporting subsequently took a sideways leap into anaesthesiology, and a man dressed as a birthday present.

Making Sleep Safer

Just like in physics, the early years of anaesthesiology had a problem with infinities. In that the aim was to put patients to sleep for a finite amount of time, but on the rare occasion, this would inadvertently extend to infinity. Before 1954, quite how often deaths occurred from anaesthesia is difficult to say as mortality reporting was anecdotal.12 The first large observational study on anaesthesia deaths was conducted by Beecher and Todd, who looked at 599,548 surgical patients, putting the death rate due to anaesthesia as 1 in 1561.13

Today, general anaesthesia is almost as safe as commercial airline travel (mortality rate is approximately 1 in 250,000 for healthy patients and 1 in 10,000-15,000 for unhealthy patients14). So, what happened? How did anaesthesiology become so safe?

Believe it or not, a researcher named Jeffrey Cooper (and the research team he was part of) accidentally made anaesthesiology safer. In 1972, Cooper thought he had been recruited to the bioengineering unit of the department of anaesthesiology at Massachusetts General Hospital to be an engineer. In an interview with the Center for Medical Simulation,15 he said the recruiter had a different idea in mind:

The person who brought me here, brought me here actually to work privately for his company on the side (which I hadn’t appreciated) because I had been doing this work on biogalvanic pacemakers. So, I was in this group not knowing exactly what I was supposed to do.

Fortunately for Cooper, Randy Meyer - an anaesthesiologist at the group - frequently took him to the operating room. Meyer helped Cooper see the issues with anaesthesiology, particularly with how people made mistakes while working with technology. To prevent these kinds of mistakes from occurring, the group decided to design and build a computer-driven anaesthesia machine.16

While working on the machine, Cooper was invited as a plus-one to a Halloween party.17 Dressed as a birthday present, he just so happened to sit next to Ron Pickett while carving pumpkins.18 Pickett was organising a NATO sponsored conference on human factors in healthcare. After realising Cooper was working on trying to prevent errors using anaesthesia machines, he invited him to present at the conference.

While Cooper was giving his talk, a man called Mel Rudolf was sitting in the audience. Rudolf worked for the American Institutes for Research, a company which used the critical incident technique to study human factors. From Jeffrey Cooper’s interview again:

Mel came up to me after the talk and said: “boy you have a great laboratory to study [anaesthesia mistakes]. Did you ever hear of the critical incident technique?” I said “no”. And one thing led to another and… we started to study errors in anaesthesia. We thought it was about errors with technology and equipment, but when [people told us their stories]… they weren’t mostly about equipment. They were about everything.

Between January 1975 and April 1977, Cooper and his research colleagues interviewed anaesthesiologists, staff members and residents at Massachusetts General Hospital.19 Using the critical incident technique, they managed to codify the types of preventable incidents involving anaesthesia and published their findings in a 1978 paper.

The critical incident technique was developed by John Flanagan (and collaborators) to select and classify aircrews during World War II as part of the Aviation Psychology Program within the U.S. Army Air Forces. It was a five-step generalised qualitative research procedure for “gathering certain important facts concerning behavior in defined situations”.20 While it had a broad application, it was particularly useful in studying mistakes.

Within medicine, Dentistry was the first to use the technique in 195321 to evaluate student performance.22 In 1970, it was used to classify whether actions of physicians during a critical incident had beneficial or detrimental effects on a patient. Before the paper authored by Cooper and his group in 1978, the only time the critical incident technique was specifically used to study errors was a very brief 1960 study of errors in drug administration by nursing staff.

Through the broad nature of the critical incident technique, Jeffrey Cooper uncovered a wide range of human factor mistakes within anaesthesiology. Most importantly, the study by Cooper and colleagues showed the importance of recording and analysing incidents that didn’t end in mortality.

While the work of Cooper and colleagues provided a template for the development of incident reporting systems and their analysis in anaesthesiology,23 the study on its own wasn’t enough to spark a wider patient safety movement. If the procedure for incident reporting came from aviation, the motivation to implement it came from another familiar source of medical change: a health insurance crisis.

The Malpractice problem

While a plane crashed into a mountain, resulting in a revolution in aviation reporting systems in the mid-1970s, Doctors in the United States were struggling to find insurance coverage. The number of malpractice insurance claims, as well as the amounts awarded, were increasing rapidly.24 The crisis was particularly pronounced in California. As a result of multi-million-dollar settlements, malpractice insurance premiums were rising by up to 400%. More problematic, however, was the exodus of many insurance firms from the market due to the losses incurred from the increased number of claims.

The need to explore alternative malpractice insurance systems resulted in the California Medical Insurance Feasibility Study. From the 1978 paper by Mills:

What is needed, in contrast to the existing malpractice trials under tort law,25 is a system that will cost less to administer, and will stabilize compensation through scheduled, standardized benefits. In this way, patients who have disabilities as a result of health care management could be fairly compensated automatically, without having to prove fault. However, reasonable cost estimates for such alternative plans cannot be made without valid information concerning the type, frequency and severity of those disabilities for which compensation might be paid.

In other words, there was no data on how big a problem malpractice was. The California Study looked at a random sample of 20,864 inpatient charts from 23 California hospitals. They found that approximately four percent of patients who were admitted to hospital suffered a potential compensable event, with 17% of these events due to negligence.

While several solutions were implemented to reduce the number of malpractice claims (and monetary amounts claimed for each) by the Californian Government, the underlying factors remained unchanged. Claims as well as monetary damages continued to rise at a constant rate. This subsequently led to another mini-crisis in the mid-1980s.

The now decade old California study remained the only source of information on the incidence of iatrogenic harm and malpractice. Howard Hiatt, dean of the Harvard School of Public Health and James Vorenberg, dean of the Harvard Law School, wanted to rectify the situation.26

They, along with other colleagues, conceived of a study like the California one, but larger and, importantly, sampling patients that represented the population. All they needed was funding - a task easier said than done. Various institutions in Massachusetts thought the study was a terrible idea.27 Fortunately, or unfortunately, depending on one’s viewpoint, New York State was struggling with spending on medical liability claims. The Governor, Mario Cuomo, was happy to fund the project.

The Harvard Medical Practice Study (HMPS) was carried out in the late 1980s.28 A random sample of 30,121 hospital records from 51 hospitals (within New York state) over the 1984 calendar year was reviewed. The researchers estimated that 98,609 adverse events occurred, with 13,451 (13.6%) leading to death.

If these rates were representative of the population, the study implied that 1.3 million patients were injured by medical care, with 180,000 dying from these injuries. This was much higher than the researchers had anticipated.

An uncomfortable truth

Lucian Leape was encouraged to interview as a researcher for the Harvard Medical Practice Study six months after it began and immediately did not want anything to do with it.29 He had spent the previous year studying epidemiology and statistics in the hope of making a career change from academic paediatric surgery to health policy, and Leape didn’t want to waste time on malpractice, an issue that he saw no reasonable prospect for change.

Fortunately, Howard Hiatt managed to convince Leape of the underlying aims of the project: to expose the frequency of medical errors. The Harvard study ended up revealing something much more striking than the 98,609 adverse events. Two thirds of the events were caused by system errors that were detectable in the medical records. In other words, they were preventable.

This fact spurred Leape’s interest in patient safety. After studying the human factors literature from fields outside medicine, he wrote a paper titled Error in medicine where he laid out how the healthcare system could be changed to prevent errors.

The Harvard Study and the Error in medicine paper helped to inspire further research into medical errors.30 In combination with high profile medical mistakes covered in the media, a patient safety movement started to build through the 1990s.

Patient safety reporting systems started to be set up. In the United States, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) initiated a sentinel event reporting system for hospitals in 1996. The introduction of the MedMARx program, an internet-based anonymous system for hospital medication errors, occurred in 1997. Many states introduced or improved their mandatory reporting systems. Australia introduced the Australian Incident Monitoring System (AIMS), and the University of Basle in Switzerland set up a Critical Incident Reporting System (CIRS) for anaesthetists.31

Generally, however, patient safety reporting systems tended to be very specific or very local.32 It would take a patient safety revolution for the proliferation of reporting systems to truly ramp up.

The Patient Safety Revolution

Towards the end of the 1990s, the patient safety movement was slowly growing in the form of committees, conferences and reports. This culminated in the Institute of Medicine’s (IOM’s)33 Quality of Care Committee. Throughout 1999, they met with various experts and discussed ways to improve patient safety and quality of care. Two reports would be written. The first, titled To Err is Human: Building a Safer Health System, focused on patient safety.34

Amongst the many recommendations, the IOM report made two specifically about reporting systems. For accountability of medical professionals, the Quality of Care Committee recommended that a national mandatory reporting system be established for adverse events that resulted in death or serious harm. For learning and improvement, the committee encouraged the development of voluntary reporting systems.

The response to the report was beyond what any of the committee members imagined.35 Quite why the report cut through the noise to influence government officials and medical professionals, while also increasing public awareness, has been debated. Whatever the reason(s), there is no doubt that it did.36

The U.S. federal government sprang into action (which might be a surprise to many). The Quality Interagency Coordination task force (QuIC) responded to the report with extensive recommendations on actions to be taken. This included a detailed pathway to a national mandatory reporting system and a thorough plan on review and implementation of voluntary systems.37

It is difficult to express how significant To Err is Human was.38 I could tell you it has been cited over 27,000 times in a quarter of a century. I could show you a graph of how the research literature on patient safety tripled shortly after the report was published. Or I could note that the rate of biomedical US federally funded patient safety research awards increased by over 2800%. But it still wouldn’t convey how the conversation about patient safety changed at the turn of the century.

Starting in the early 2000s, high income countries started to create patient safety organisations and national reporting systems. Some countries started with sentinel events (e.g. Sweden & Norway) or focused on specific clinical domains (e.g. France – nosocomial infections), others were developed independent of government (e.g. Australia). The UK, Denmark and Ireland developed comprehensive wide-scale reporting systems.39

After the World Health Organisation (WHO) wrote draft guidelines for the development of adverse event reporting and learning systems in 2005, middle to lower income countries began the process of developing their own systems. The WHO, collaborating with many countries, subsequently developed the Minimum Information Model in 2016, with the intention of standardising incident reporting forms worldwide.40

Where are we today?

Despite the early explosion in the early 2000s, progress has generally been slow worldwide. While 94% of the 108 surveyed countries in WHO’s 2024 Global patient safety report have adverse medical reaction reporting systems, only a third of them have specific national patient safety programmes.

This is perhaps an indicator of where reporting systems in the world stand today. Trying to write about what happened after the year 2000 has given me a headache. Not because the fundamental logic of modern patient safety incident reporting systems is hard to understand, but rather due to the sheer number and diversity of systems. There are so many, of so many different types, in different configurations, either interacting with each other, or kept separate. Trying to map it in my head has been a terribly frustrating experience.

So instead, let’s try to build our own. In the next article, we will imagine an alternate universe where we have free rein to plan and develop a national patient safety incident reporting system.

What could possibly go wrong?

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5

This may have been a development from an earlier accident report form.

Writing in a 1953 edition of the “Hospitals” journal (Vol 27, Issue 3, pg 90-92), Kent Francis exclaims that:

The American Hospital Association and the National Safety Council have achieved a reasonable facsimile of the impossible—an accident report form on which can be reported injuries to patients, staff and the visiting public.

Francis also attaches the form:

This is article 8 in the Psyverse #2 series (and article 4 in the Thin line series). Find previous articles in the compendium.

James Dow didn’t have time. The tragedy of Flight 514, alongside other crashes and safety failures publicised in late 1974, resulted in rapidly decreasing confidence in the FAA’s ability to function.1 This perceived lethargy had likely cost the then-current FAA Administrator, Alexander Butterfield, his job.2 When James Dow took over as Acting Administrator in April 1975, he understood his term would likely be a matter of months, not years. But he also knew his authority would be limited if FAA staff saw him merely as a transitory figure. So, he acted, and made decisions, as if he were a permanent appointee.

Dow had over 30 years of experience within the FAA, working on some of the most significant development projects.3 This deep understanding of the bureaucratic machinery helped him to push through a whole heap of initiatives in a matter of months. One of these initiatives was the Aviation Safety Reporting Program (ASRP), a non-punitive incident reporting system, announced in May 1975.

Dow’s inspiration for the ASRP came from the FAA’s Near Midair Collision reporting program (NMAC), which ran from 1968 – 1972. The NMAC was essentially the same as all the other near miss reporting systems mentioned in this series, apart from one crucial difference. Reporters had extensive transactional immunity.4 Even if the reporter had been reckless, or evidence had been found from other sources outside of the report of a misdemeanour, the FAA could not apply punitive action.5 By submitting a report, the reporter received immunity in return from the FAA – hence “transactional”.

Just like a previous FAA near miss program under FAA administrator Quesada, this immunity provision was dropped with little warning in 1971, before the entire program was ultimately cancelled in 1972 due to the subsequent dramatic drop off in reporting.6

Dow wanted to both reignite and extend the cancelled NMAC through the ASRP. Reignite by reintroducing transactional immunity (with one caveat7) and extend through full incident reporting. Essentially, the Aviation Safety Reporting Program was almost identical to the incident reporting program Oscar Bakke proposed two decades earlier – but with enhanced immunity provisions.

And, in similar fashion to all the previous reporting systems devised by the FAA, the ASRP ultimately failed – in record time. The number of reports that came in were so low, Dow changed course after just 3 months. Reporting to the same organisation that gave out punitive measures and had previously taken away the immunity without any notice likely deterred reporters.

With an air of familiarity to the events that led up to Project SCAN 15 years prior, Dow turned to a third party to ensure anonymity from the FAA. But this time it wasn’t a non-profit organisation. It was a governmental one – NASA.

Building the ASRS

For an agency that had just put men on the moon, you might think overseeing an aviation reporting system for ordinary mortal folk wouldn’t be the type of small step NASA liked to take. But this would be forgetting the first “A” in the National Aeronautics and Space Agency. A deep knowledge of aeronautical principles,8 combined with a sky-high reputation and lack of regulatory function, made NASA one of the most viable, trustworthy and impartial third parties. All the FAA needed to do was knock on the right door. Fortunately, they did.

Charles Billings had a curious career path. He trained as a medical doctor, then served in the US Air Force as a squadron flight surgeon. After his military service, he worked as an aviation medicine researcher at Ohio State University before joining the human factors group at NASA Ames Laboratory. A couple of years into his role as a medical research officer, he received a knock on his door.

Billings was tasked by the FAA to lead the construction and implementation of a new incident reporting system – the Aviation Safety Reporting System (ASRS). The FAA would fund the program, but it would be run entirely by NASA. With the help of aviation psychologist George Cooper and research pilot John Lauber, Billings developed a rough protocol for the ASRS. After three weeks of refinement through NASA management, the protocol was presented to the FAA and quickly accepted.9

A Memorandum of Agreement was signed on the 15^th of August 1975. The ASRS would be designed to perform four primary functions:

(1) receipt de-identification and initial processing; (2) analysis and interpretation; (3) dissemination of reports and other data; and (4) system evaluation and review.10

with NASA developing procedures for receiving, de-identifying and processing ASRS reports, ready for operation on April 15^th, 1976. This meant Billings and the NASA Ames team had just six months to build an incident reporting system to accommodate the entire United States.11

Within two months, a procedure for day-to-day operation of the system had been written. A formal request for a proposal was made to find a contractor to help process the ASRS reports. Which was awarded to Batelle a week before the deadline. On April 15^th, Advisory Circular 00-46A announcing the ASRS came into effect, and reports soon came flooding in. Initially 250 per week, before eventually settling to 150. This was more than expected.

I’m not sure what it would’ve been like to have had piles of reports turn up every day, procedures being updated on the fly, without a working data entry computer system. The word “stressful” comes to mind.12 In this situation, the team followed a “first-thing-first” policy, with a focus on establishing satisfactory procedures, administrative control over the growing number of reports, and the first stages of the ASRS reporting process. Which went as follows13:

After an incident, an air traffic controller or pilot would fill out a report form, the entirety of which fit on a double-sided piece of paper.14 Once the form reached NASA, it was reviewed for appropriateness and whether it contained time critical information.15 The report would then be sent off to an analyst – an aviation expert (such as an ex-pilot, etc.) – to identify and categorise potential causal factors, among other actions.16 Sometimes, the analyst would determine that more information from the reporter was required. In this case, the reporter would be called up for clarifications – termed a “callback”.17

After analysis, the slip containing the contact information of the reports was cut off and returned to the reporter as proof it had been received and analysed. The report had therefore been preliminarily “deidentified” and was subsequently sent off to be encoded.

In the initial absence of a database, this involved transcribing pertinent information and analysis on to a separate record sheet (to varying degrees of completion) which was subsequently filed away until the ASRS processing procedure had been fully developed. The original reports were then destroyed after an arbitrary waiting period.

By the 6th of July 1976, Batelle had demonstrated they were ready to process, analyse and store individual reports and began the next day. Nevertheless, by Christmas 1976, the “ingestion of data had so far exceeded digestive capacity that strong measures were required”.

A team of Batelle researchers started tackling the fixed-field and free text analysis, as well as the encoding procedure18. Then, they introduced a new step: diagnostics. Each encoded analysis would have an additional diagnostics sheet where standardised keywords were applied to classify the types of causal factors in each incident. Useful for future research and trend analysis. Quite incredibly, in the early stages of the prototype ASRS, a single person developed the diagnostic lexicon and applied it. Each and every one of the hundreds of reports per week had to go through a single diagnostician.19

The ASRS project was overseen by an advisory subcommittee.20 Over the next few years, they helped to direct the further development and refinement of the ASRS as it went from prototype to fully functioning system. Eventually, the backlog of paper encoded records became fully digitised on Batelle’s database, realising Bobby Allen’s vision of computer utilisation. There was, however, one significant problem with the rapid change and development of the ASRS procedures. While the ASRS team understood how the system worked, almost no one else did.

Within the first couple of years, Advisory Circulars, brochures and posters publicising the ASRS were widely distributed to facilities by NASA and the FAA. But this wasn’t enough. In surveys, it was evident that “a large proportion of the flying population lacked knowledge of the ASRS and its immunity features.”21 The Advisory subcommittee therefore recommended that NASA develop an accessible way to communicate with the wide range of professionals that worked in the aviation industry.

The task fell onto the shoulders of Rex Hardy, a decorated WWII aviator and corporate test pilot,22 who, along with Billings, created CALLBACK. A monthly, short, easy to read newsletter that addresses a serious subject in aviation safety. Rex, however, had a “distaste for well-intentioned but dull exhortations on safety”, so he endeavoured to make the publication interesting, instructive, entertaining, and god forbid, funny. It seemed to work. CALLBACK is still in production today.

Promotion was crucial to the success of the ASRS. The program existed in a political environment. Having the aviation community not only onside, but actively advocating for the system helps provide political pressure to keep the program funded and running, as the writers of the NASA ASRS history put it:

Even if all the other motivators are present in the reporter community, a lack of appreciation for the purpose and scope of the program or difficulty in obtaining the means to communicate will eventually result in the termination of an effective and valuable safety system.

One of the greatest strengths of the ASRS, that promoters could point to, was the immunity policy. The transactional immunity policy – a submission of a report led to a waiver of disciplinary action from the FAA for everyone involved in an incident – was strengthened from the FAA’s failed Aviation Safety Reporting Program that the ASRS replaced. Reckless operation was partially protected. With the addition of NASA as a third party, reporters also had use immunity – NASA could not share any info from the reports which might reveal the identity of the reporter to the FAA. Given the lack of trust between the Aviation community and the FAA, immunity became a vital provision to incentivise incident reporting.23

As the 1970s drew to a close, the value of the ASRS was felt by both the developers of the ASRS and the reporters using it.24 Everything was going swimmingly, until the 31^st of January 1979, when John Winant,25 who had recently compiled a report evaluating the ASRS, received a letter from the FAA:

The FAA letter… largely addressed the immunity issue, a topic which had not been mentioned in my report to him. [T]he text said, “We are definitely considering a program of modification” which would “allow enforcement proceedings against any person who has allegedly violated an [FAA regulation]….” This meant the limited immunity provision would be canceled…. The pertinent paragraph concluded with this sentence: “Before taking such action, further discussion with you and appropriate NASA officials is contemplated.” To me, and particularly in the context of prior concerns over the immunity issue, the word “discussion” had a distinct meaning. I believe, in reading that sentence, that a process of consultation would begin shortly, and that full opportunity to modify the FAA intention would exist. That belief was shattered within 24 hours.

On February 2^nd, the FAA told Winant that they were going to go through with the cancellation of the immunity provision.

The mistake that almost cost immunity

When Langhorne Bond, the newly appointed FAA administrator, sat before a House of Representatives subcommittee in November 1977, he only had good words to say about the ASRS. Bond classified “NASA analysis of the aviation safety reporting system as a very healthy, constructive and professional effort”, saying later on the FAA “found the reporting system to be a helpful mechanism for assimilating as much information as possible…”. In a March 1978 letter to NASA Administrator Robert Frosch, Bond said the ASRS was providing “needed and valuable insight” confirming the FAA “was not contemplating a change of the [immunity] provision”.26

Just one year later, Bond’s opinion appeared to have changed drastically. In a speech to the National Aviation Club on March 16^th 1979, he announced a U-turn on ASRS immunity, giving his main argument:

[O]ne part of the program causes me grave concern. This is the cloak of immunity that a violator can draw around himself simply by turning himself in to NASA […]. The guarantee of immunity, I’m afraid, can be too easily corrupted into a license to endanger hundreds of lives with no fear of punishment. I want to continue the immunity program - but I want it modified to end these abuses. Under these modifications, airmen will no longer be able to claim immunity for violations – witnessed by others – of safety regulations

So, what changed Bond’s mind?

This, as Charles Billings explained in a 1998 talk to the National Patient Safety Foundation, was due to a political oversight:

We (or, rather, I), in my naiveté made an assumption. I assumed that since the chief of the FAA was asking for [the ASRS], the FAA wanted it. This was a bad mistake.

Over the past 21 years, the NASA Aviation Safety Reporting System has had the support of virtually everybody in the United States aviation community to a greater or lesser extent with one notable exception. The exception is the people under the FAA Administrator—and there are roughly 22,000 of them—whom he did not consult before he came to NASA and asked for an incident reporting system. We do well to remember that a primary issue is who may be hurt by reporting. This is especially of concern where use of immunity (and, originally in the ASRS, transactional immunity as well) is a prominent feature.

What was the largest segment of the FAA aside from the air traffic control system? Divisions involving regulations and enforcement. Whose enmity did we earn the day this thing was announced? Those who had to make it work in the community. That is the worst mistake I made in 40 years.

Due to the pace at which James Dow set up the ASRP and subsequent ASRS in 1975, regional FAA officials were not consulted. After implementation of the program, the morale of regional FAA personnel was negatively affected by the waiver of disciplinary action because more of their efforts to conduct investigations ended up fruitless. Efforts to explain why the immunity provision was important were few and far between and largely ineffective. It seems as if discontent slowly built until the autumn of 1978, when regional FAA directors expressed to Bond that the “Aviation Safety Reporting Program had not provided any significant, useful data not already known to us through FAA programs”.27

Political regional pressure, as well as pressure to show the FAA had safety under control after the 1978 deregulation act, likely led to the reversal of the opinion of Langhorne Bond.

In Bond’s proposed modification, the anonymity provision provided to reporters would be strengthened, while the blanket transactional immunity – waiver of disciplinary action – was to be removed entirely. If the FAA found incriminating evidence of a disciplinary infraction from other sources other than an ASRS report, the fact that a report was submitted would not mean the investigation was cancelled – it would carry on.28

The response from the aviation community was overwhelmingly negative. In short, they had been burned by the FAA too many times before. The fact the ASRS could be abused was acknowledged by commentators, but the effect of the potential loss of reports would be far more detrimental to safety than any current abuse. Their view can be summed up by Frank Munley29:

Unlike Mr. Bond, I’m firmly convinced that the problem of human error is better tackled by a scientific investigation of the true causes of hazardous situations, as opposed to a punitive approach which ignores the intent of the violator.

Rather than a win or a loss for either the FAA or aviation community, the battle for immunity ended in a draw. Due to the arguably unimpressive performance at the April 1979 committee hearing by Bond,30 he decided against returning for a follow up hearing and worked with the ASRS subcommittee to come to a compromise. Instead of full loss of transactional immunity, some would be maintained, while the strengthened anonymity provisions remained.31

Ironically, the weaker transactional immunity provisions seemed to improve the quality of reporting. Before the reduced immunity, only one reporter needed to send in a report for everyone involved in an incident to have immunity. With the new provisions, every person had to send in a report to gain individual immunity. The ASRS therefore received different perspectives from the same incident, enhancing the potential for analysis.

Since the late 1970s, the procedure of the Aviation Safety Reporting System has pretty much remained the same. It has become a mainstay of safety prevention in US Aviation, with over 2 million reports submitted since its inception. In recent years, additional voluntary reporting programs have been introduced within the U.S. to cover more specific and nuanced areas of aviation.32

The success of the ASRS prompted other nations to set up their own voluntary reporting systems, such as the UK’s CHIRP in 1982, Brazil’s RCSV in 1997, and Korea’s KAIRS in 2000. The proliferation of reporting systems led to the International Confidential Aviation Safety Systems (ICASS) Group, which facilitates the sharing of information between nations, among other roles.33

Today, through voluntary reporting systems, the aviation industry has managed to reliably take advantage of the thin line between normality and catastrophe. In medicine, I don’t think we can make the same claim.

Though, the history of patient safety reporting systems goes back much further than you might believe. In the age of Hawker Hurricanes and Supermarine Spitfires, just before they defended the British Isles from the Luftwaffe, a member of medicine’s unsung heroes was already advocating for the use of reporting systems…

Come back next week for the final instalment of the thin line series: the surprising history of patient safety reporting systems.

If you have enjoyed the story of the, not so smooth, Mr. Bond and his unintentional mission to alienate the entire aviation community, please do drop a❤️, restack 🔄 or share 🔗. It would be much appreciated!

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13

NASA actually asked a contractor to handle the data processing, as allowed by the Memorandum. This flow chart was subsequently replaced by the following one, by Batelle incorporated. Given its complexity and the poor quality of the scan, I thought I would stick to the preliminary program definition.

14

The developers reviewed previous reporting form make-ups from predecessor programs and had psychologists help design the form. They opted for a simplistic approach so the form would be as easy as possible to fill in, while still getting across the required information for analysis.

Comparing the old ASRP form with the new ASRS one:

This is article 7 in the Psyverse #2 series (and article 3 in the Thin line series). For previous articles, see the compendium.

This piece will draw heavily from an excellent article, A Different Approach: The crash of TWA flight 514 by Admiral Cloudberg, and Chapter 7 of Delivering the Right Stuff by Andrew J. Dingee. I recommend reading both for more information.

On the 1st of December 1974, a plane crashed into a mountain. It was not the first one in history to do so, nor the last. In isolation, the crash of Trans World Airlines (TWA) flight 514, tragically killing all 92 people on board, holds no more significance than any other deadly plane crash. Why flight 514 is considered one of the most influential accidents in aviation safety history has little to do with the crash itself, but with a near miss six weeks earlier.

In October 1974,1 a plane nearly crashed into a mountain. 40 miles out, at an altitude of 7,000 feet, flight controllers cleared a United Airlines flight for an instrument approach to Washington Dulles Airport without a minimum altitude.2

On the plan view of the Dulles “approach plate” (see Fig 1 below) three official flight paths - each with associated distance (indicated above path) and minimum altitude (below path) - converged to the Round Hill beacon point, or “initial approach fix”, 11 nautical miles (NM) out from the “final approach fix”. From Round Hill, a single flight path led to this “final approach fix” 6 NM out from Runway 12.3

On the profile view of the approach plate, on the other hand, only the final approach fix and the final 6 NM are displayed with a minimum altitude of 1800 feet. The flight path from Round Hill, with accompanying minimum altitude,4 to the final approach fix is not displayed. This discrepancy is what likely led to the United Airlines flight near miss.

When Air Traffic Control (ATC) cleared the United Airlines flight for an approach to land without a minimum altitude clearance, the pilot assumed they could descend to the minimum altitude of 1800 ft, clearly displayed on the profile view approach plate.5

Fortunately for the United Crew, they were in good weather conditions and could see that they were about to fly dangerously close to the peak of Mount Weather, so they adjusted accordingly.6 After landing, the pilots filled out an incident report and sent it to the United Airlines Event Review Committee (ERC). This was part of a new procedure as part of a program put in place by United in January 1974 called the Flight Safety Awareness Program. Once the report was reviewed by the ERC, a safety alert was sent out to all United Pilots about the Dulles Runway 12 approach discrepancy. But only United Pilots. Pilots employed by other airlines never saw this incident report – no federal system was in place to facilitate distribution.

The crash of Flight 514

One hour before Flight 514 crashed into a mountain, the pilots of an American Airlines flight made the same mistake that United’s pilots had made six weeks earlier. Seven miles out from Mount Weather, at 1800 ft, the American Airlines plane was heading straight towards the mountain. This time, the weather conditions were poor. The pilot decided to radio ATC at Dulles to ask what altitude they should be at. ATC told them to climb to 3,400 feet immediately. A crash was averted, for an hour.7

TWA Flight 514 took off from Port Columbus International Airport8 at 10:24 am, heading for Washington National Airport. But twelve minutes after take-off, the pilots were ordered to divert to Dulles airport - severe weather (high winds, snow and rain) had resulted in the closure of Washington National.9

Due to the diversion, the plane did not initially follow the official published flight path - instead intercepting the 300 degree (120 degree on the approach plate) radial 13km earlier than the plate’s initial approach fix at Round Hill.

At 11:04, 44 NM from Dulles Airport, ATC cleared flight 514 to approach runway 12, again without a minimum altitude. Just like the United and American Airlines flights, the pilot descended to 1800 ft, thinking the ATC had implicitly given him clearance and would point out if he was at the wrong altitude.10

While they were descending, the pilot had another look at the approach plate and noticed that “this dumb sheet says it’s thirty-four hundred [feet] to Round Hill — is our minimum altitude”. Due to confirmation bias, a discussion on this discrepancy was cut short before it could even begin.11 All the crew managed to miss the Mount Weather peak heights of 1764 and 1930 feet, which they were directly flying over.12

Once they reached 1,800 feet, they encountered significant turbulence and downdrafts, causing frequent altitude oscillations. They received only two altitude warnings: the first, seven seconds before impact, and the second, two seconds before impact. It was too late for the pilots to take any corrective action, and the plane crashed into Mount Weather, killing everyone on board.13

After the NTSB released their report of the Flight 514 crash, the FAA sprang into action and introduced what would become the Aviation Safety Reporting System or ASRS. The story of Flight 514 is often told as the turning point in the development of the ASRS, with the unique set of circumstances surrounding the crash being the key motivator. It is therefore interesting to note the nearly identical crash that occurred six years earlier.

Groundhog day

On the 25^th of October 1968, a plane crashed into a mountain. It was not the first one in history to do so, nor the last. In isolation, the crash of Northeast Airlines Flight 946, tragically killing 32 out of 42 occupants, holds no more significance than any other deadly plane crash. Out of isolation, this remains the case. Why flight 946 is considered just another accident in aviation safety history, has little to do with the crash itself (or the previous near miss), but the continuing inaction of the FAA.

The runway 25 approach plate of Lebanon Municipal Airport, North Hampshire, from 1968 looks confusing, to say the least. Since only one radar station existed without distance measuring equipment (i.e. just VOR, no DME),14 and the airport was nestled in amongst a very hilly region, the entirety of the approach plate flight paths were restricted to one single radial.

A flight at cruising altitude coming in from any direction was supposed to first head to the VOR (radar) station location, then head northeast (radial 066 degrees) for around 10 Nautical Miles. During this phase, flights could not descend below 4200 ft. This point – 10 NM from the VOR – can be thought of as the start of the final approach (see Fig 6, indicated by purple circle), but is not an official “fix”.

Flying north, a pilot was supposed to circle around in a clockwise direction – ensuring a minimum altitude of 4200 feet throughout - eventually ending up inbounds, travelling towards the VOR radar station and Lebanon runway 25 (the 246 degree radial). The flight was then supposed to descend to a minimum altitude of 2800 feet. Only once the pilot had passed the VOR station, could they descend no lower than 1800 feet until they could fly under Visual Flight Rules or “the time to fly to the airport had been flown”.15

The problem with this approach centres on the radar system. A VOR station can only provide a pilot with information about which radial it is on in relation to the station, and whether flying along that radial would take you towards (TO) or away from (FROM) the radar station. So, when coming into land at runway 25, the indicator on a pilot’s Course Deviation Indicator (CDI) would have a radial of 246 degrees selected, with “TO” on the display. As the plane passed over the VOR radar station, this “TO” would switch to “FROM”. There is a nice explanation on how this works from Clearflight.

At some point before Flight 946 crashed, a Northeast Airlines flight was coming in to land at runway 25. It was overcast, with occasional breaks in cloud. The pilots saw the needle on their display jump and the CDI switch from “TO” to “FROM”. Thinking they had just passed the VOR station, they started to descend. Once they reached 2000 feet, the pilots noticed the CDI had switched back to “TO”. The captain then saw how close they were to the ground through one of the breaks in the cloud and immediately climbed back up to a safe altitude.

Once they had safely landed, they reported this incident to the local FAA maintenance technician, who checked the VOR radar station and found no irregularities. The pilot “did not, nor was he required to by [the FAA’s] current procedures … [to] report this occurrence to any central unit within [the FAA].”16

Flight 946 took off 47 minutes late from Boston. It was late in the evening, sunlight was fading, and the conditions were overcast with occasional breaks in cloud. Arriving into the vicinity of Lebanon, the crew communicated to ATC that they were going to perform a “standard instrument approach”. For some reason, the crew decided not to perform the published instrument approach procedure.17

Flying due north-west, flight 946 attempted to take a shortcut, avoiding the initial VOR station approach starting point entirely. They tried to tack on to the very end of the approach procedure, turning anticlockwise onto the final approach path.

The flight then continuously descended, not stopping at the minimum altitude of 2800 feet, until they eventually crashed into the top of a rocky, heavily wooded mountain, 2237 feet above sea level.

In the subsequent investigation, the NTSB tested for possible interference that could affect a pilot’s CDI display. They found areas along the approach where “course roughness manifested itself on the Course Deviation Indicator” but could not recreate the switch from “TO” to “FROM”. The NTSB concluded that the probable cause of the crash was the premature descent based on navigational instrument indications that they were about to pass the VOR station.

Due to the potential for an incident report from the previous near miss preventing the deadly crash of Flight 946, the NTSB believed that “the FAA should provide the leadership in developing and implementing an industrywide operational incident reporting system”. The FAA responded with:

In regard to the suggested industrywide operational incident reporting system, this is now being accomplished by our system of issuing telegraphic alerts and operations bulletins […]. We will conduct a complete review of current incident reporting procedures.18

On the 1^st of December 1974, TWA Flight 514 crashed into a mountain. So the FAA quickly introduced an actual industrywide operational incident reporting system, at least six years too late.

The series within a series continues next week.

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If you enjoyed today’s article, please consider gifting a heart ❤️, restacking 🔄 or sharing 🔗. It would be much appreciated.

If you enjoyed today’s article, please consider gifting a heart ❤️, restacking 🔄 or sharing 🔗. It would be much appreciated.

If you enjoyed today’s article, please consider gifting a heart ❤️, restacking 🔄 or sharing 🔗. It would be much appreciated.

If you enjoyed today’s article, please…

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This is article 6 in the Psyverse #2 series (and article 2 in the Thin line series). For previous articles, see the compendium.

On November 1st 1958,1 General Elwood Richard Quesada became the first Federal Aviation Agency (FAA) administrator at a time when air traffic control was “a dangerous hodgepodge of uncoordinated civil and military operations”.2 Quesada introduced a new program of cooperative military-civilian control of airspace, and instigated a “no nonsense” approach for civil aviation pilots, bringing them up to “military standards”:

[Quesada] sent his inspectors through a demanding Air Force checkout course in the KC-135 (the military version of the Boeing 707), and took the course himself… ‘Now,’ [Quesada] says, ‘the FAA inspectors can fly these jets better than the man they’re checking out.’3

The inspectors picked up on everything, with the FAA jumping on infractions with heavy fines. Quesada justified his actions by saying:

When you go to the ticket counter and buy a ticket…you don’t know who’s going to fly you, or anything about his training, or the airline’s equipment – nothing. The public acts in faith, faith in this system, and we’ll see to backing up that faith. I’m here to represent the public, and dammit, the public will be protected.4

Administrators and pilots reluctantly agreed that this cleanup campaign by Quesada was a good thing, but it came at a cost.

Animosity grew between pilots and the FAA. Pilots felt that the inspectors were overreaching, picking up on questionable minor indiscretions resulting in fines, instead of improving systemic problems.

For example, Quesada seemed to believe greater pilot discipline was the main answer to the near miss problem. On March 3^rd, 1959, he sent a letter to Clarence Sayen, the President of the Air Line Pilots Association (ALPA), noting as a passenger, “all too often the pilot is in the cabin talking to passengers or engaging in endeavours not essential to his duties”. He drew attention to a regulation stating that all flight crew members should “remain at their respective stations when the aeroplane is taking off or landing, and while on route except when the absence of one such flight crew member is necessary in connection with his regular duties.”

Sayen, in response, pointed out the impracticalities of Quesada’s request. Under the regulations in force at the time, only the pilot was required to be qualified to operate the specific controls of the aircraft being flown.5 Further, it was the pilot’s responsibility to ensure the passenger cabin was safe,6 and considering some flights were 12 hours long “the sensible pilot gets out of his seat occasionally for exercise… to retain his alertness”. He noted that ALPA had been pushing for a requirement of specific aircraft copilot training for years.7

Sayen noted that FAA inspectors were now timing the pilot’s visits to the passenger cabin, filing violations that were not consistent – the absence times ranged from 7 to 23 minutes. He accused the inspectors of turning Quesada’s letter into a rigid rule through a “childish Gestapo program”.8

The animosity had a particular impact on near miss reporting. According to Joseph Hartranft, president of the Aircraft Owners and Pilots Association (AOPA), when the transfer of safety regulation from the Civil Aeronautics Board (CAB) to the FAA began on 1 January 1959,9 near miss reports previously sent to the CAB were now heading to the FAA – without pilots knowing this had happened.10 When the pilots were eventually informed on March 9 1959, through a press release, it did not mention that pilots no longer had immunity, as that provision only rested with the CAB.

In the six-month period between January and July 1959, pilots were being charged by the FAA with violations based on their own voluntary reports. The pilots, understandably, were not very happy about this, and near miss report submissions dropped off dramatically.

When the CAB near miss program was shut down in July 1959, the FAA took on the responsibility of collecting and analysing near miss reports. Except almost none were now being submitted.11 Senator Engle, in the Review of the Federal Aviation Act Senate hearing in 1960, illustrated the situation:

The FAA invited pilots to report near misses. And so a lot of dumb country pilots like me – and I wasn’t one of them who made the report – reported a near miss; and found himself cited because he was at the wrong altitude or something… I noticed this magazine, the Pilot’s magazine, published by AOPA, just said quit sending in the reports; don’t report or you will get clobbered […]. This is the kind of an attitude that doesn’t contribute to air safety.12

Clarence Sayen asserted that the non-immunity “policy of the FAA is fallacious and should be reversed immediately.”13 It was not reversed.14 It took a new administrator of the FAA, Najeeb Halaby, to reignite a near miss reporting program when he took office on March 3^rd, 1961.

Due to the damage in trust caused by the previous administration, Halaby found that pilots were unwilling to report to the FAA, even with the promise of immunity.15 Therefore, he asked a third party, the nonprofit non-governmental organisation called the Flight Safety Foundation (FSF), to run a near miss reporting program. It was called Project SCAN (System for Collection and Analysis of Near mid-air collision reports) and initially ran for six months starting on July 1^st 1961, before being extended to a year, finally concluding on June 30^th 1962.16

If a pilot had a near miss, they would send a form to the FSF.17 It was anonymous – even if the pilot signed their name, the form would be destroyed once relevant information had been taken from it. Given the Flight Safety Foundation did not have the power to issue punitive action and did not pass on identifying information of the pilot to the FAA, pilots had immunity. However, similar to the previous Civil Aviation Board program, if the information of the incident came through other means, the voluntary form submission did not grant immunity.

The main difference between Project SCAN and previous programs was, according to a 1961 article in Aerospace Safety Magazine:

Where the analyzed information suggests the need for changes of any kind – changes in procedures, traffic patterns, even aircraft cockpit or instrument design – specific recommendations will be formulated and submitted to the FAA for action.… [T]his is where Project SCAN differs.… [Previous] programs have dealt solely with statistics, the ‘how manys’ instead of the ‘how comes.’ Project SCAN deals with the ‘how comes’ or the ‘whys’ as well as the ‘how manys’

Project SCAN received 2,577 reports during its year in operation and seemed to be popular. Some pilots even returned forms without a near miss, simply to state their approval of the program. Interestingly, the FAA also kept its own near miss reporting program, and pilots only turned in 549 reports over the same period – the anonymity and immunity provisions resulted in 2.5 times more reports.18

At the same time as Project SCAN, a small group of the International Air Transport Association (IATA) airline operators decided to form an information exchange “experiment”.19 Information related to safety reported by pilots under one airline operator would be shared with all the others around the world. Arguably, this was the first International civil aviation incident reporting system.20

During most of the 1960s, however, a U.S. national voluntary near miss and/or incident reporting system seemed to once more become relegated to discussions in safety conferences.21

The main push for a national incident reporting system came from the CAB director of aviation safety, and later director of the National Transportation Safety Board (NTSB),22 Bobby R. Allen. He was particularly interested in the role of the computer in accident prevention. Instead of condensing incident reports down into simple, broadly defined categories (such as pilot error, mechanical deficiencies, inadequate maintenance, etc.), Allen argued for a “bulk look” at the data. He wanted to utilise the memory and data retrieval capabilities of the computer to do a detailed statistical analysis to unpick the complex causes of accidents. And to project potential future causes of accidents through analysis of past trends.23

First, however, Allen needed data to awaken the “sleeping giant” of computational analysis. He needed an incident reporting system. This was the subject of his 1966 talk at the 19^th Annual International Air Safety Seminar in Madrid.24

In the talk, Bobby Allen highlighted how the International Air Transport Association information exchange processed incidents, quoting Boyd Ferris, a secretariat at IATA:

[W]e lump incidents and accidents together because the thin line dividing an accident involving fatalities or major damage to the aircraft from an incident in which everyone got off scot free is often nothing more than luck.

Allen then points out that:

The alarming thing is that we do not take advantage of our good fortune. Here we have a brush with disaster; a live crew and virtually intact aircraft ready to tell a story, and yet we never open the book […]. What is it, then, which stands in the way of communicating this incident information to the appropriate governmental agency for processing? Repeatedly, when this question is asked, one hears the reply – FEAR: fear of litigation; fear of regulation; fear of punitive action.25

In the late 1960s, Allen communicated with officials from the airline industry, as well as associations, to work out how to combat these fears so that an “information exchange program” could be set up.26 He found that the most stubborn fear was litigation.

Several lawyers tried to tackle the fear of litigation.27 Probably the foremost pushing against the fear was a UK lawyer named Harold Caplan, who argued that when an accident occurred, lawsuits would almost certainly follow.28 Since incident reporting would reduce the number of accidents, the number of lawsuits would therefore decrease.29

But fear is not rational. The worry for a lot of airline companies was that the information produced by incident reporting would be used against them in litigation. Caplan therefore proposed example legislation that could be used internationally to protect the exchange of safety information.30 Further, Robert Reed Gray built on an idea by Charles McErlean of United Air Lines, suggesting that liability without fault be imposed on air carriers. Litigation would only be used to decide how much to pay to survivors of victims of accidents – no blame would be asserted.31

According to the archive of Bobby Allen’s letters, significant progress was made towards an information exchange system as the 1960s were coming to a close.32 But Allen found he could not get the project over the line from proposal to implementation. He concluded:

To the question of “Why hasn’t a program been established” everyone immediately trots out the “6 symptoms of the Fear Syndrome” […]. But in the final analysis, I personally believe that the Fear Syndrome is used as an excuse for our failure to overcome the major problem of information exchange. That problem is nothing more than sitting down and writing specifications for the program.33

Allen nearly helped accomplish it. In August 1968, the Air Transport Association of America (ATA)34 and Aeronautical Radio, Incorporated (ARINC) held initial discussions about the establishment of an airline safety data bank to be used for an information exchange program. The ATA then reached out to Allen to try to have the NTSB as the custodian of the data bank, to keep the information safe. By October 1969, potential specifications and requirements for an information exchange program had been written up by ARINC and submitted to the ATA.

On December 3^rd 1969, the ATA safety committee met to discuss the ARINC report. Allen’s invitation to the meeting was withdrawn due to fears that a representative of the government in attendance would not lead to a frank exchange of industry views. Subsequently, the ATA decided they:

would not be willing to participate at this time […]. However, the airlines recognize the desirability of a program of accident/incident data analysis and exchange in the airline industry.35

ARINC recommended the ATA continue with an alternative program where the ATA would “select a non-government organization to function as data custodian”. This never came to pass. Bobby Allen died on November 17^th 1972. Despite all his efforts, he never saw the creation of an incident reporting system.

For fear to be overcome, the thin line between incident and accident had to visit Washington DC, where legislators could see the consequences of their inaction with their own eyes.

The series within a series continues next Thursday.

If you enjoyed today’s article please👻 AHH! A ghost!! … … Okay, I think the coast is clear… If you 🧟 AHHHH, gosh darn it! … Right, I’m boarding up my house🏚️ .

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17

Here is what the form looked like:

Today, we are indulging in an Inception (or Psyception), a series within a series. This is article five in the Psyverse #2 series (for previous articles, see compendium), and article one in the Thin line series.

The Psychiatric Multiverse is centred around taking an idea from another field and applying it to psychiatry. For this Psyverse series on incident reporting systems, the “other field” is aviation.

Over the next few weeks, we will explore the history of aviation incident reporting systems. As well as providing crucial lessons in our aim to build an effective reporting system in psychiatry, I think it is a story that has yet to be told.

So, without further ado, let us go back to the 1950s and the beginning of the jet age…

The United States had a problem. Since the dawn of aviation, pilots had operated mostly on a “see and be seen”1 procedure to avoid air collisions – they would visually scan for other aircraft and ensure their own aircraft was as visible as possible.2

This was okay during the 1930s and 40s when there were sparse aircraft in the sky and speeds were usually slow enough for pilots to take evasive action if necessary. However, by the early 50s, the number of planes in the sky was increasing rapidly, and the development of turboprop engines meant cruising speeds of some aircraft were approaching 250 miles per hour.3

Faster planes require more “separation”4 between other aircraft to ensure the risk of mid-air collisions is kept at a minimum. But in a congested airspace, especially around airports, this was quickly becoming unrealistic.5

The Air Line Pilots Association (ALPA) were well aware of the growing mid-air collision problem. Up until this point, problems were found and solved after collisions and the deeply unfortunate loss of life. But, talking to the Air Safety Board in a 1950 House of Representatives hearing, David Behncke, president of ALPA, noted:

Actual accidents are not the only fruitful source from which to determine the need for improvement in air safety. There are those about which the public never hears; about which you honorable gentleman seldom hear; indeed, about which no one except those very, very closely connected with the industry ever hear. These are the near accidents, the narrow squeaks, the close calls of high disaster potential. The independent Air Safety Board would find fertile ground indeed for investigation in a carefully compiled “close call” or “near accident” file. ALPA has such a file but the present air safety set-up is such that we are at a loss at times to know who should receive our reports.

During the early 1950s, near-accident (or near-miss) reporting seems to have remained a disparate practice of individual organisations running their own projects without an overarching organisation to send their reports to.6

Perhaps the closest to a nationwide scheme during this period was the “Anymouse” program introduced by the US Naval Air Force starting around 1954.7 Naval Air Force pilots were encouraged to submit anonymous reports to Naval Command whenever they nearly collided with either another aircraft or terrain. According to a 1954 article8 in Flying Safety Magazine:

[T]he idea evolves around the theory that a close shave with the reaper will probably teach a guy something. If he can pass on a bit of knowledge to the next man, then both will benefit.

In general, the military led the way in researching how to implement a near miss reporting program. It seems as far back as the 1930s, it was observed that it was more important to find out from a pilot how and why an accident occurred, than to punish the pilot for any mistakes they had made leading up to the crash.9 A research paper by the United States Air Force in 195310 suggested that a near miss reporting system without identification of the pilot provides “considerably more information on personal behaviour” than one which has the potential for evaluation or disciplinary action. Hence, the emphasis on anonymity in the Anymouse program.

In civil aviation, wider attention was given to the near miss problem through several safety meetings starting in 1953. Special attention was given to how to establish a near miss reporting program in 1954 at the meeting of airline chief pilots in Dallas Texas. Meetings between disparate airline industry groups and the Civil Aviation Board (CAB) about setting up a reporting program continued through 1955, when, finally, on February 23^rd 1956, the CAB announced Special Regulation 416 – “Voluntary Pilot Report of Near Midair (Near-Miss) Collision” – a national near miss reporting program.

Pilots were assured that they could submit reports, choosing to be anonymous, without fear of disciplinary action. Pilots had immunity. Up to a point. If information about an incident was obtained from other sources outside the voluntary report, the pilot in question could still face remedial action.

Despite this caveat, reports flooded in.11 In one year, 971 near miss reports were sent in, an average of 2.5 per day.12 Around 85% of the reports concerned near misses that were below 1,000 feet (around the height of the Eiffel Tower). In 256 of the 971, planes had narrowly avoided collision by less than 100 feet. To give some context, a Boeing 737-700 is about 100 feet in length:

According to Oscar Bakke, the safety director of the Civil Aeronautics Board (CAB), the reports confirmed that in areas with higher traffic density, there were more near misses. Interestingly, 98% of the near-misses were reported with visibility in excess of three miles, and a growing ratio of near misses over time involved jet aeroplanes – suggesting that see and be seen was indeed becoming obsolete. A final observation was that approximately half of the near misses reported by civil pilots involved a military aircraft. The near miss reporting program gave evidence for greater use of “positive control” of aircraft.13

It was recognised in the program’s May 1958 report that the CAB’s objective in collecting near miss statistics had been achieved, and that continuing the program would provide no further benefit. Therefore, the CAB proposed a new incident reporting program, with the same anonymity and immunity provisions, that would extend well beyond the near miss reporting program. On August 7^th 1958, under draft release 58-14, Oscar Bakke wrote:

The excellent response of pilots to the present program and the desirability of collecting broader information bearing upon aviation safety, leads to the belief that the program should be extended to include more than just the reporting of “near misses.” … [A]ny airman aware of in-flight, ground or procedural hazards [would be encouraged] to report them to the Board […]. The program under consideration would place less emphasis on the statistical aspects of the reports and direct attention primarily to the particular circumstances involved in each report.

But it was too late. The program could not be set up before the Federal Aviation Act of 1958 transferred the CAB’s regulatory function to the Federal Aviation Agency. Subsequently, on July 15^th 1959, the voluntary near miss reporting program under special regulation SR-416A was shut down.

It took the United States 16 years before an almost identical incident reporting program to Oscar Bakke’s 58-14 proposal, was finally introduced. The reason? The usual culprit at the heart of any inaction: Fear.

The inception-like “Thin line” series within a series continues next week.

Thanks for indulging this foray into aviation history. If you know anyone with an interest in aviation, please do share 🔗 the article with them!

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8

Reading old magazines, one cannot ignore the rampant sexism. Now and then, random images of scantily clad women pop up. Weirdly, sometimes with little to no relevance to the information on the page (do not look at page 29 of the 1954 article linked to this footnote).

A photo in the August 1961 edition of Military Air Transport Service flyer, I think gives a hint at what women thought about the sexism:

We need to address the elephant in the room. Not only do patient safety reporting systems already exist, but they have existed for at least a quarter of a century.1 While tempting to say, “case closed!” on an excellent example of a system from fields like aviation or nuclear safety being implemented within psychiatry2 and immediately high-tailing it out of here, the current situation is bedevilled by nuance. So much nuance that it has been difficult to wrap my head around it. And I love wrapping my head around things.3

Yes, patient safety reporting systems exist, but their effectiveness has been recently questioned by multiple authors.4 Despite significant investment in reporting systems, large numbers of patients continue to be harmed each year. It is still the case that for most areas of medicine, the safest time to receive healthcare treatment is tomorrow. This contrasts with other fields like aviation and the nuclear industry, where reporting systems have been a highly successful tool for helping improve safety through system change.5

Many reasons for the underwhelming performance of patient safety reporting systems have been suggested, along with proposed solutions.6 We are going to focus on their characteristics. Arguably, while patient safety incident reporting systems are widespread, few can claim to be integrated, (inter-)national,7 non-punitive, confidential, independent and inclusive. Why are these six characteristics important? We shall find out.8

Firstly, however, it would probably be a good idea to explain what a patient safety reporting system is.

The aim of a reporting system is to catch incidents, which, according to the World Health Organisation (WHO), broadly fall into three categories: near miss, no harm incident and harmful incident.9 The harmful incidents subsequently fall into two further categories: adverse events and adverse reactions. With “events” being preventable harm and “reactions” non-preventable harm. Within these broad categories, more specific classifications have been used and proposed.10

When a healthcare professional (or indeed a patient) comes across an incident, whether through direct involvement or as a bystander, they fill out a form. Depending on the type of system, reporting an incident may be mandatory or voluntary.

Mandatory systems are primarily used to hold healthcare providers accountable. They focus on the severe incidents, like sentinel events, otherwise known as “Never Events”. An example of a severe incident could be the amputation of the wrong leg during surgery or an incorrect medication given to a patient, leading to their death.11

Voluntary systems are primarily used for learning. These generally focus on near misses or very minimal patient harm. One example would be a prescription error (wrong dose, wrong drug, etc.) that is caught by a pharmacist before it reaches the patient. Voluntary incident reports submitted by healthcare reporters are indicators of potential systemic (procedural, technological, etc.) changes that need to be made.12

In either case, the incident form that a healthcare professional submits will generally have a section which classifies the incident (patient information, incident time/type/severity,13 etc.) to allow sorting and trend analysis. It will also have a free text section for the reporter to provide the story of what happened. The WHO proposed a Minimal Information model to help healthcare providers develop their own incident reporting form.

Once completed, the clinician/patient sends the form off (electronically nowadays) to an organisation that will sort and analyse the reports. If there are incident reports of interest, an investigative body could send a team of experts to review cases and investigate. After completion, different policies or procedures would then be recommended in a report and implemented to change the latent conditions, thereby preventing future incidents from occurring (depending on the reporting system in question and the seriousness of the incident, a reprimand of staff involved may also be issued).

Designing an effective patient safety reporting system is easier said than done. Out of the many characteristics and factors that need to be considered, arguably, the following are some of the most important.

Integrated

My initial intention for this Psyverse series was to focus exclusively on incident reporting systems in psychiatry. I found this an impossible task. Every time I wanted to make a point, the evidence and analysis leaked into other areas of patient safety. Whether that was the type of culture that encouraged reporting, or how investigations into incidents needed to be guided by an incident reporting system. Patient safety is an interconnected web of incredibly complex systems that influence, and are influenced by, each other.14

In industries such as aviation, investigation into harm (accidents) has been developed since at least the 1930s, with reporting systems being developed since the 1950s.15 An entire safety management system has been slowly developed over the course of nearly a century. In contrast, healthcare systems have attempted to translate safety knowledge from other sectors into a fully functional patient safety system within the space of a couple of decades.

The result is that patient safety incident reporting is not properly integrated within a wider patient safety system. Too often, they have been used as a repository to gather statistics and keep track of the number and types of incidents, rather than as a learning tool.16 An incident report is only the start of the learning process; it is only a “window on the system”, from Vincent (2004):

Incident reports by themselves…tell you comparatively little about causes and prevention…. Reports are often brief and fragmented; they are not easily classified or pigeon holed. Making sense of them requires clinical expertise and a good understanding of the task, the context, and the many factors that may contribute to an adverse outcome.

An effective patient safety reporting system requires substantive analytical, investigative and regulatory systems to lean on. With each system intricately connected to the others, and the wider healthcare system, through procedure and legislation. Patient safety also needs to be promoted and communicated to build a safety culture.

In other words, the development of Safety Management Systems (SMSs) is desperately needed.17 Only then can the learnings, discovered through incident reports and investigated by experts, be implemented into principles, processes and practices, then subsequently followed by healthcare staff.

(Inter-)National

While there is value in a system that picks up on a specific local incident, then develops a specific local solution, this is not where the real value of a reporting system lies. Reporting systems are as much about preventing incidents occurring over the entire system as they are about finding specific cases.

Say we have an incident where there are two patients with the same first name (say Jacob M. and Jacob Y.) sitting next to each other, awaiting a routine blood transfusion. A unit of red blood cells was taken from the refrigerator, and during the setup of the transfusion for Jacob M., it was realised the blood cells were actually for the other patient - Jacob Y.18

If we don’t have a national reporting system, we are relying on every single local blood transfusion provider to pick up on this type of name mix up incident, report it, have a team investigate it, and then enact a correct latent condition change that would fix the problem (rather than a change that would only half-fix it, such as guidance or training etc.). Not only is this horrendously inefficient and expensive, but it is also a lot of work for each local provider to ensure patients stay safe.

A national reporting system’s role is to find common occurring problems as they start arising, have a national investigative body examine them, and then disseminate the solution to all local healthcare providers across the country. Meaning that for most providers, the incident is prevented from occurring in the first place.

While the UK has a national patient reporting system,19 many countries around the world, including the United States, do not.20 Given the number of countries with fragmented local reporting systems that do not permit the sharing of information between them, how many times has the wheel been reinvented? Perhaps more importantly, how many different shapes has the wheel been reinvented into?

While I have focused on national systems, there is scope for an international sharing of incident reporting. Healthcare is a global phenomenon, and there will be problems generic enough to apply to many countries around the world. But more importantly, there are many countries with rudimentary reporting systems that could benefit from the learnings of countries with more advanced ones.

A final point is that the introduction of a national reporting system does not mean the shutting down of local ones. Firstly, if every incident in the country were reported to a national agency, it would be overwhelmed quickly. Indeed, overreporting is a significant issue. Secondly, in many healthcare settings, solutions may need to be tailored to the individual characteristics of each healthcare provider (e.g. number of staff, layout of the hospital, number of beds, how busy the hospital is, etc.).

Non-Punitive

Lucian Leape, one of the experts at the forefront of pushing for increased patient safety awareness, once testified to the U.S. Congress:

The paradox [of punitive measures] is that the single greatest impediment to error prevention is that we punish people for making them.21

Keeping to the theme of apparent paradoxes, while encouraging healthcare staff to “report it all” to a national system tends to result in overreporting, having punitive consequences for reporting incidents tends to result in underreporting.22 Out of the many barriers to reporting,23 the most prominent seems to be the consequence of disciplinary action after submitting a report to a reporting system.24

Assuming the vast majority of healthcare professionals don’t intend to commit errors, some of the most important incident reports could be the ones most fraught with potential disciplinary consequences. This is because these reports may point to an aspect of the system unintentionally designed to encourage clinicians to go against regulations. Logically, it follows that by removing the consequence of disciplinary action, more of these types of errors will be reported.

But the picture is not quite as simple as legislating the removal of punitive measures resulting from incident report submissions. Whether a system is mandatory (generally focused on accountability - with greater likelihood of punitive measures), or voluntary (generally focused on learning - usually non-punitive), underreporting rates are still significant.

Some of this can be attributed to barriers such as confusion about what to report or time constraints. A likely more significant reason for underreporting can be attributed to blame culture and surrounding factors.

Which is why the organisation running the reporting system needs to be…

Independent

Perhaps the most widespread problem of patient safety reporting systems is that they are often run by the same organisation that also deals with punitive measures. Even if a reporting system is formally non-punitive, conflicts of interest25 can result in informal negative consequences, like reduced status or career prospects. Healthcare professionals may feel psychologically unsafe, reducing the likelihood of incident reporting.

An independent organisation running a reporting system would allow confidence that reports won’t be used punitively against the reporter, as the independent organisation would simply not have the power to punish. Recently, in the UK and Norway, independent investigative organisations have been set up for this very purpose.

Independence also likely provides psychological safety to healthcare reporters, as the information they submit won’t be seen by anyone working within the same organisation. This is especially relevant for many current local, hospital-wide reporting systems where staff report incidents directly to their superiors (e.g. supervisors or line managers). Not only does this mean that the superior could censor reports to administrators because of a conflict of interest (say, the line manager had performance targets they needed to keep to), but they could also use the incident reports as evidence to punish staff. Voluntary reporting systems have been used in this way within the United States.26

Ideally, an independent safety team within each local healthcare provider would operate and manage the incident reporting system. They would then report the issues to the board directly.27

Confidential

For readers familiar with reporting systems, you may have noticed I have not included “anonymous” alongside confidential. This is despite the fact that many reporting systems are either completely anonymous or provide a way to report anonymously. Some authors have argued for confidentiality over anonymity.28 Notably, the WHO also omitted anonymity in their initial report on the ideal incident reporting system, including only confidentiality.29

The primary issue is that anonymous reporting systems are problematic when it comes to the investigative process. Usually, reports require some form of follow-up, as investigators often have questions about the information provided by reporters, and reports also generally have information missing. In an anonymous system, follow-up isn’t possible,30 making investigations more difficult.

For the reporters submitting to anonymous systems, the lack of feedback after submission is also a significant problem. It can encourage submitting and forgetting of reports, reduce responsibility for local improvement, and, most importantly, a lack of feedback deters reporters from submitting future incident reports. With an anonymous system, reporters do not know if anyone has read their report, never mind whether the issue they have a stake in has led to any meaningful change or investigation.31

Confidential systems allow for the possibility of feedback to occur, opening the door to active participation in patient safety from all parties. Ideally, a system would allow for every report to be confidential, with an option for the reporter to stay anonymous.

Inclusive

Out of the many research papers and guidance on patient safety reporting systems, there appears to be a gaping hole. Patient contributions. Despite a 2020 WHO report advising that “[t]he best reporting systems also include and encourage patient generated reports”, the vast majority of incident reporting systems don’t appear to allow a patient to submit reports.32 Of the ones that do, patient contributions make up a tiny fraction of the total number of reports.33

In my opinion, this is a significant oversight. Unlike in industries like aviation, where the passengers are typically that, passengers, patients are part of the process. Almost every medical decision is discussed with the patient, and the patient is the ultimate decider on the treatment option they choose to go with (also holding a veto on any potential treatment offered).34

Patients have information that healthcare professionals do not have access to. While doctors see many patients, patients see many doctors… and surgeons… and nurses… and pharmacists… You get the picture. A patient’s care experience is different to healthcare professionals – as Pozzobon et al. (2023) puts it: “Patients are the only care team member present at every interaction across their care journey”.35

Patients can therefore identify mistakes and offer insights that would otherwise be inaccessible to staff. As an example, five out of my six psychiatrists never realised they made diagnostic and prescription mistakes during my care. By the time I learned the key information highlighting these errors, I was usually being seen by the next (or the next + 1) psychiatrist.

Given what I’ve mentioned so far, I don’t think it is too far-fetched to say that patients should be encouraged to write incident reports when the opportunity arises. But I don’t think this encouragement is occurring. In the decade I have been receiving treatment, I did not know that as a patient in the UK, I could have filled out an incident form to the NHS’s Learning From Patient Safety Events (LFPSE) reporting system. Heck, in my decade as a patient, I didn’t know that incident reporting systems even existed.

Whenever I encountered a problem with my care, the response from healthcare professionals was either an attempt to fix my problem (and only my problem) or a directive towards a complaints procedure.36 Of all the rhetoric about moving towards learning and away from blame, why is it that, for every problem I’ve had with the healthcare system, staff have failed to look for learning and instead asked me who I want to blame?

As a patient, I would much rather a system be fixed so that the mistakes that occurred to me yesterday don’t occur to somebody else tomorrow, than see one particular clinician be reprimanded and learn nothing. I am not alone in this sentiment.37

I think the time has come to include patients in patient safety reporting.

What about Psychiatry?

You may have noticed this article has been pretty light on psychiatry. If you were to read the patient safety literature, you would notice a similar phenomenon. Up until 2019, there had only been two reviews that examined patient safety in a mental health context.38 The barriers to incident reporting in psychiatry have been so significant, Russotto et al. (2024) used expert opinion as an alternative source of information to study inpatient psychiatric incidents. Research specifically about psychiatric patient safety in a community setting is practically nonexistent.

For the research that has been conducted, many of the studies are published in speciality-specific journals (e.g. a psychiatric nursing journal) instead of patient safety ones. Consequently, psychiatric patient safety studies are not only separated from general patient safety literature, they are separated from each other. The scientific practice of building on a diverse array of past studies has become extremely difficult.39

Given the paucity of research and unique challenges associated with patient safety in mental health,40 the field of psychiatry may very well be the area in medicine most in need of effective incident reporting systems.

But, before we start thinking about how to design such a system, it is worth exploring the history of an industry that has already gone through the inevitable trials and tribulations of incident reporting implementation: Aviation.

The series continues next week, where we will start our exploration into the history of aviation reporting systems.

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There is no getting around the fact that health and safety is a very boring subject.

This was made clear to me when I volunteered to give an induction talk to new PhD students at the start of my third year. I arrived early, in the middle of the health and safety officer’s talk. I watched from the back of the room as he heroically tackled a plethora of health and safety directives. He spoke passionately about who to talk to in case something went wrong, where information on safe handling of equipment could be found, and empathetically reassured the onlooking students that everyone makes mistakes – it is far better to find help when things go wrong than try to fix things on one’s own.

It was a thoroughly impressive talk by a thoroughly impressive speaker. “Gosh, how am I going to follow that?” I remember thinking as I walked nervously up to the front.

When I turned to face the sea of eyes, I immediately understood my miscalculation. I had never seen a more bored audience in my life. Out of the sullen faces, heads on desks and emotionally vacant expressions, one student was faced 90 degrees away from me, staring directly at a newly painted wall. “How am I going to follow that?” I thought a second time. I tried my best to energise and inspire the new cohort of PhD students, but all I managed was a quiet titter of laughter halfway through.

“That was brilliant Alex!” the postgraduate secretary commented, rushing up to greet me after, “I’ve never seen the new students laugh after the health and safety talk”. This might be the highest praise I have ever received.

Talking about health and safety is inevitably boring. But that doesn’t mean that doing health and safety should be boring. So rather than try to persuade you that the mind-numbingly long documents of guidelines and strategies and directives are somehow secretly sexy, or lecture you on the life-saving importance of health and safety rules that you all must follow to a tee, I’m going to argue that when health and safety is done well, you don’t see it as health and safety. It is a set of systems and culture that are part of the everyday machinations of one’s job.

Since health and safety applies to all jobs, from postal workers to gardeners to healthcare professionals, the theory behind this set of systems and culture is generalisable. So I hope you will join me in this exploration of Human factors, the subject concerning health and safety at work.1

Part of a good health and safety system/culture is knowing what to do when a mistake occurs. How do we rectify it? To answer this question, I need to talk about a lawn mower and Swiss cheese.

Four for the sides, please

Let’s say an employee named “Axel” has been hired by a lawnmower company as a door-to-door salesman. The company has just released a brand-new lawnmower. Axel goes around neighbourhoods looking for unkempt lawns to demonstrate the mighty power of the cutter 3000. Lo and behold, Axel finds just the lawn. And not only have the occupiers not thrown him off their property immediately, they’ve agreed for Axel to show them how the mower works.

As Axel is setting up the lawnmower, the occupiers ask him to set it on the highest setting. “No problemo!” Axel confidently replies, as he puts his hands on the push bar, strides confidently down the first horizontal line of lawn, and…

Axel has only gone and buzz-cutted a bald line into the turf! He slowly turns his head to see the open-mouthed expressions of the couple that so keenly invited him to demonstrate the cutter-3000. It ends how most sales attempts end. Axel gets chucked out by the occupiers.

Now, in this circumstance (which definitely did not happen with me and my own lawn), the primal urge is to blame.2 The mistake was Axel’s fault. In the context of a group of people, like in an organisation, this is what is called a blame culture. When someone makes a mistake, often the reaction is to find a small number of people who are responsible (who are then punished), drawing attention away from possible systemic issues. From The design of everyday things3 by Don Norman:

Humans err continually; it is an intrinsic part of our nature. System design should take this into account. Pinning the blame on the person may be a comfortable way to proceed, but why was the system ever designed so that a single act by a single person could cause calamity? Worse, blaming the person without fixing the root, underlying cause does not fix the problem: the same error is likely to be repeated by someone else.

Rather than immediately throwing Axel out, thus leaving a non-symmetric sideburnless garden and the lack of what is otherwise an excellent lawnmower, the friendly couple could have asked Axel what went wrong. Together they could try to piece together how the mistake was made, to understand how it could be prevented in future. This is the opposite4 of a blame culture – a learning culture (sometimes known as a “supporting culture” or “no-blame” culture).

In communication with the lawnmower company, changes could be made to the procedure or design of the cutter 3000. Ensuring no lawn will feel naked again. If the company keeps finding that Axel seems to have a pathological obsession with removing as much grass as possible, while other salesmen have stopped buzz-cutting grass, the company could ask Axel further questions. If he were found to have made the mistake on purpose,5 disciplinary procedures could be undertaken. This is a “just culture”, which lies between a blame and a learning culture.6 While learning is the ultimate aim, individuals have responsibility over their actions and can be sent for further training or disciplined if found to be engaging in risky behaviour deliberately.

Let us say that Axel made an honest mistake. How could we learn from it?

Slicing Swiss Cheese

First, we need a model of how mistakes occur within an organisational system. Fortunately, a British Psychologist called James Reason came up with such a model in the late 1980s. He imagined a series of layers representing defences and safeguards within a system to guard against hazards.7 Rather than being perfect, these defences have holes in them. Rob Lee, Director of the Bureau of Air Safety Investigation in Canberra at the time, suggested to Reason that the sequence of layers with holes looked a lot like Swiss cheese. Reason took this idea and ran with it, publishing a figure utilising Swiss cheese in his 2000 article Human error: models and management. And thus, the Swiss cheese model was born.

So, as you can see from the Swiss cheese figure above, when anyone makes even the tiniest mistake, everyone dies.

Wait…

That isn’t right…

Can we look at the Swiss cheese figure again?

James Reason has only gone and made an error in a paper about how errors are made! You cannot just copy and paste the same slice of Swiss cheese!8 It seems like human laziness has triumphed once again.

You see how easy it is to blame?

So, let us use the Swiss cheese model to help us understand how James Reason, the creator of the Swiss cheese model, made a mistake while trying to communicate the Swiss cheese model.

Firstly, we need to understand what the Swiss cheese model is actually supposed to represent.

The layers of cheese are defences against a source of harm (hazard), so that an event that causes harm to a person (loss) doesn’t occur. These can range from organisational influences to environmental and psychological conditions. The holes are gaps in these defences (e.g. toxic work culture, budget constraints, bugs in code, weakness in a safety barrier, etc.).9

The layers of cheese are not identical in nature. Together, they represent a system of defences as a whole, but each individual layer represents a different part of the system. In other words, the holes won’t be in the same places. The layers form a hierarchy, with the start of the arrow going through the “blunt end”, and the head of the arrow through the “sharp end”.

The blunt end is usually remote from any accident (or loss) in both time and space. The slices of cheese here represent senior decision makers, managers, the design of the system procedures, and organisational culture. The failures, or holes in the Swiss cheese at this end, are “latent conditions”. From Human error: models and management by James Reason:

[Latent conditions] arise from decisions made by designers, builders, procedure writers, and top level management…. Latent conditions have two kinds of adverse effect: they can translate into error provoking conditions within the local workplace (for example, time pressure, understaffing, inadequate equipment, fatigue, and inexperience) and they can create longlasting holes or weaknesses in the defences (untrustworthy alarms and indicators, unworkable procedures, design and construction deficiencies, etc). Latent conditions—as the term suggests—may lie dormant within the system for many years before they combine with active failures and local triggers to create an accident opportunity.

The sharp end is where frontline workers10 are in direct contact with the system environment, whether that be another person (e.g. a patient), a machine (e.g. an aeroplane), or a topology (e.g. a quarry). The slices of cheese here represent the state of the system conditions or the psychological/physical state of the frontline worker. The holes in these slices of cheese are called “active failures”, or “unsafe acts”. These are slips, lapses, fumbles, mistakes and procedural violations.11

Note that the holes in the Swiss cheese represent both active failures and latent conditions. Generally, latent conditions are higher up the hierarchy, nearer the hazard, with active failures lower down. Early versions of the Swiss cheese model had distinct explicit representations for each layer. But given the heterogeneity12 of health and safety systems, the layers were eventually left unnamed so that different systems could be labelled in the way that suited them best.13

Importantly, as James Reason notes in the very paper he published the misleading Swiss cheese figure in:

[Unlike in Swiss cheese the] holes are continually opening, shutting, and shifting their location. The presence of holes in any one “slice” does not normally cause a bad outcome. Usually this can happen only when the holes in many layers momentarily line up to permit a trajectory of accident opportunity—bringing hazards into damaging contact with victims.

So, the Swiss cheese figure is supposed to represent a snapshot in time when all the holes manage to line up. Perhaps a more accurate Swiss Cheese Model representation would be this figure:

Each of the layers has holes in different places and different sizes. The arrow touches at least one of the sides of the holes it passes through, which helps convey the momentary nature of the holes lining up. Finally, the arrow passes through a very tiny hole in one of the layers to convey that the hole has just opened up.14

So, back to Reason’s Swiss cheese figure from earlier. The “unsafe acts” that Reason made were copying and pasting the same Swiss Cheese and drawing an arrow directly through the middle of the holes.15 To get to the bottom of the latent conditions, a root cause analysis would need to take place. This is where an investigation of the “unsafe act” and the events leading up to it attempts to determine where the holes in the system were. In lieu of a root cause analysis, we can guess that some of the latent conditions were: the likely clunky software at the time of publishing (2000s), the publishing checks, and the peer review system.16

Swiss Cheesing the lawnmower

With our understanding of the Swiss cheese model in mind, let us look back at the lawnmower, and my active failures… No wait! Axel’s active failures…

Ack. I cannot keep up this ingenious facade any longer. Alas, it was me… I embarrassingly buzz-cut my own lawn.

With that out of the way, my first active failure was that I didn’t read the manual fully. I didn’t learn the ins and outs of how the lawnmower worked.

Then, I set the height of the lawnmower without double-checking it was correct. Finally, I didn’t test out the lawnmower on a very small inconsequential patch of grass, much like what one would do when testing paint colour.

The lawnmower company could give out directives for owners to follow as a slip of paper in the box the lawnmower came in. However, this would be like a band-aid (or “plaster” if British) over a continuously cracking system. Wiegmann et al. (2022) illustrate the shortcomings of such local fixes through a classic Dutch childhood story. A young boy named Hans uses his fingers to plug holes in a dam near his village, saving the inhabitants from flooding.

While such corrective actions are needed, and should be implemented, they often do not address the underlying causes of the problem (i.e., the reasons for the leak in the dam). It is just a matter of time before the next hole opens up. But what happens when little Hans ultimately runs out of fingers and toes to plug up the new holes that will eventually occur? Clearly, there is a need for the development other solutions that are implemented upstream from the village and dam. Perhaps the water upstream can be rerouted, or other dams put in place. Whatever intervention we come up with, it needs to reduce the pressure on the dam so that other holes don’t emerge.

In other words, we need to address the latent conditions in the system so that new holes don’t occur, or even better, so that Hans doesn’t need to put his fingers in the dam holes17 in the first place.18

What were the latent conditions in my lawnmower escapade? To find out, we need to do an investigation.

First of all, how did my buzz-cut mistake occur? Well, I set up the lawnmower by unfolding the push bar, putting in the battery, and plugging in the safety key. Then I looked at the tag attached to the push bar to check if the lawnmower was set at the right height. According to the label, the lawnmower was originally set to “low”, and I wanted it on “high”, so I reached down from my standing position behind the lawnmower and pulled the red handle to the “high” position. I made no question of this. The handle being up on the lawnmower, to indicate the high setting, was intuitive to me.

Then, I turned the lawnmower on, walked forward, and made my lawn feel embarrassed for a couple of weeks.

So, what on earth happened? Well. When you take a look at the side of the lawnmower, the answer reveals itself.

Pulling the red lever back lowered the lawnmower, not raised it! Since I pulled the lever back while standing behind the lawnmower, the height indicators were obscured from view. Similarly, while standing, I could not easily see that the lawnmower had lowered down. And since from my position, everything made intuitive sense, my brain was not on the lookout for things to go wrong – I was focused on pushing the lawnmower to mow the grass.

My guess is the tag was intended to be viewed in the folded position of the lawnmower handle, when it was close to the lever. In other words, the tag was supposed to be viewed while facing the front of the lawnmower instead of standing behind it.19

Possible design solutions for these latent conditions20 could be to change the inner mechanism of the lawnmower lever so that the higher up position corresponds to the lawnmower being higher. Pictographs of some short grass and long grass could be placed on top of the lawnmower at each corresponding end of the lever “hole” so that when a person reaches down to change the lever, they can confirm it is at the setting they want. The tag on the lawnmower could be attached to the other side of the handle, and perhaps an outline of a lawnmower surrounding the lever diagram could show clearly which end is the front of the lawnmower and which is the back.

Reporting the problem

Now that I have spotted the active failures and latent conditions21 after committing my unsafe act (as well as devised possible solutions to plug some of these holes in the Swiss cheese), how could I communicate it back to the lawnmower company?

I could just send them an email. But I might just get a message back saying “we have read your concerns and passed your feedback on to the relevant person”, knowing full well the administrator on the other end of the email has probably deleted it. However, if the lawnmower company had a form I could fill in, specifically for me to report a mistake, I would be more confident my concerns would be looked at.22

These forms would be part of something called a safety reporting system. Originating from industries like aviation and nuclear, they provide a means for front-line workers to report unsafe acts.

While in my lawnmower scenario, I have personally made the effort to conduct a very informal investigation, in the real world,23 front-line professionals usually don’t have the time, nor would be very happy about, being unpaid investigators. While it is beneficial for staff to be involved as much as possible in every aspect of safety, most of this job would go to an investigator. What we can expect is for front-line professionals to report their mistakes.

Compared to the aviation and nuclear industries, the implementation of reporting systems within healthcare is relatively recent. Mostly occurring within the last twenty-five years or so. It has gone… well… I think it wouldn’t be too controversial to say the jury is out at the moment.

The series continues next Thursday.

If you didn’t find the article too cheesy or full of holes, please consider giving it a heart ❤️.
And if you know someone who would appreciate an unnecessarily thorough analysis of a bald stripe in a lawn, please do restack 🔄 or share 🔗. My lawn and I would be grateful!

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14

As a final note on the Swiss cheese model, it is meant to be a heuristic to help a general audience understand how organisations could become safer. Safety science has to encompass all the factors involved in the complex interaction of people with other people, as well as people with the environment. It is probably fair to say that nothing in safety science is simple.

Many criticisms of the Swiss cheese model fail to take into account other, more detailed versions of the heuristic Reason produced, such as:

I recommend the excellent article by Larouzee and Le Coze (2020) for an extensive look at the history of the Swiss cheese model.

Welcome to the psychiatric multiverse! Here, we will explore how ideas from other fields might be able to improve the psychiatric system. This is the second article of our in-depth series on incident reporting systems. It is also a follow-up to my previous article on mistakes.

Most people can adapt to new situations. Eventually.

In the no man’s land between “new situation” and “eventually”, things can often look a little baffling. There is perhaps no better example than a sports team suddenly adopting a completely new strategy, winning lots of games, and their opponents responding by… doing the same losing strategy as before.

I know how it feels to be one of these befuddling opponents. The day after my severe reaction to the Selective Serotonin Reuptake Inhibitor (SSRI) antidepressant Sertraline, when I was suddenly bombarded by a bunch of severe anxiety symptoms that required a hospital visit, I went into work. Because. Erm. My brain thought the best strategy to deal with this scary new situation was to do exactly what I had done before. That day was a workday, after all. I lasted about 15 minutes before heading back home.

Having definitely, absolutely, 100% learned my lesson, I decided to continue trying to go into work over the next couple of days. On my last attempt, I didn’t even make it to the bus stop.

The first thing I wanted to do when I moved back to my mum’s place to recover was book a meeting with a psychiatrist. When my internal universe changed, initially, all I wanted was a name for it. I knew what happened to me was serious, and I trusted the UK’s mental healthcare system would get me the urgent help I needed, post haste.

Two months later, naivety fully banished from my psyche, I left the first meeting with my psychiatrist relieved.

She told me that what I had was something she had seen before – an “alertion response” to the Sertraline.1 In fact, she was really pleased to see me in her office at such a young age – she told me that most of the patients she saw with a condition like mine were in their 40s or 50s. I think she meant this as some kind of reassurance. But all I thought was “you mean I managed to fit 40 or 50 years of stress into 23?”

Nevertheless, I was hopeful. I thought I had something rare amongst the general population, but something common for people who end up in the office of a psychiatrist. Things were going to get better.

A month later, I was crying in the same psychiatrist’s office. Things had gotten considerably worse, and I still didn’t know what on earth was wrong with me. I was upset because no matter how hard I was trying, I could not get through to the psychiatrist how serious my condition was. Something finally clicked when she asked “Are you okay to drive home?”

I replied “Umm... My mum drove me here? I’m not even close to being able to drive.”

She asked to see my mum, who came in and helped communicate more effectively my family history of psychiatric conditions and the symptoms I had after taking the Sertraline. She gave me a retrospective diagnosis of serotonin syndrome, adding that I was most likely on the bipolar spectrum.2

When my mum and I left the psychiatrist’s office and turned to go down the stairs, I lifted my head to see her office door slightly ajar. Framed by this gap, I saw my psychiatrist leaning over her desk, head in her hands. It can be easy as a patient to forget that mistakes can have a toll on clinicians too.

My psychiatrist had given me a prescription for Olanzapine, an antipsychotic. Over the next day or so, I agonised over whether I should take it. The potential side effects terrified me. One of the safest psychiatric medications had completely upended my internal reality – goodness knows what a “serious” drug could do. In the end, I decided against taking Olanzapine and continued down the psychotherapy route. I was just too scared of potential permanent side effects, however unlikely they were to occur.

A few months into psychotherapy, I decided to trial another medication. I was only given eight months off from my PhD, and it became clear I wasn’t going to recover in time to return. Having been discharged by my psychiatrist, I went to my GP. He wrote to my local NHS mental health centre. A psychiatrist at the centre made a recommendation, oddly, through a letter. I never saw this psychiatrist. The recommendation was for the SNRI antidepressant Venlafaxine.

The Serotonin out of Serotonin and Noradrenaline Reuptake Inhibitor terrified me, but my GP reassured me that Venlafaxine mostly acted on Noradrenaline reuptake inhibition. Thinking there were few other options, I decided to start a trial of the drug.

I went unbelievably slowly on the titration up to a therapeutic dose of 150mg. On several occasions, it felt eerily similar to my experience of taking Sertraline. I put this down to what I thought was the tiny S of Venlafaxine’s SNRI classification. After weeks of slow titration, I finally made it to 150 mg.

I didn’t feel that much different to before, but hoped Venlafaxine would act as a buffer against the most stressful events. Eventually, I did make it back to the PhD.

I took Venlafaxine for three years. During this period, I tried to come off it twice. Both times, I started to feel worse once titrating down. I therefore concluded Venlafaxine must have been helping. In fact, the opposite was true. By the time I finished the PhD, I was the sickest I had ever been. The deterioration was so slow, I never noticed.

In the years since, I have both learned more about Venlafaxine and seen the reports about me by my first psychiatrist – the one who prescribed Olanzapine.

Venlafaxine was not doing what I thought. My GP got the Venlafaxine mechanism of action the wrong way round. At low doses, Venlafaxine acts more on serotonin reuptake inhibition. It only starts having any meaningful Noradrenaline reuptake inhibition at around 225 mg per day. The highest I ever reached was 150 mg. In essence, I was taking a weak SSRI – the type of medication which caused my severe reaction – for three years.

A sentence in the last paragraph of my first psychiatrist’s report (4 months before I took the Venlafaxine) showed the SNRI prescription mistake was inherently preventable. She wrote:

[It is] very important that [Alex] avoids all the SSRI and SNRI medications.

I think it's natural to be angry knowing things could have turned out very differently. But shaking one’s fist at the world doesn’t help improve it. After all the mistakes that were made during my care, I wanted to learn why they were made. I wanted to learn how the kinds of mistakes that happened to me could be prevented from happening to other people.

What I found was a subject much more vast, more complex, more curious than anything I had ever come across in my life.

The series will continue next Thursday.

Thanks for reading the Multiverse Psychiatric. If I enjoyed this story about mistkes, please do give it a hearth❤️. It is much appreciated!

Psyverse #2 (Reporting systems)

Psyverse #1 (Stories)

Psyverse #0 (Why I write)

Nowadays, I don’t really like milestones – the moments in life generally seen as times to celebrate and reflect on the past. I don’t celebrate my birthday, or Christmas, or any holiday. This isn’t because I’m a negative nelly. I don’t spend the generally recognised periods of “time-off” in a darkened room lambasting the pointlessness of existence (though I don’t begrudge anyone that does – life can seem pointless at times). Nor do I sit in a mountaintop lair, plotting to steal presents from pacifists, with very strange hair.1

All in all, I think I’m a fairly optimistic individual. The main reason I don’t celebrate or reflect on milestones is because chronic illness doesn’t generally allow it.2 Periods of rest and recuperation are a social privilege afforded to the healthy. Holidays, and the like, require energy and help to organise. It is presumed that brain reward mechanisms are functional and in place, so that participants can actually enjoy the time off. Not to mention that usually the experience is much better with other people – effort is required to cultivate and maintain relationships so that people will join you in your time off.

Living with chronic illness means I have no energy to spare. The vast majority of my time is spent attempting a single goal: to get healthy. Any widely recognised day of rest is spent like all the others. Routines, practices, management, monitoring & slow build-up of functioning. Unfortunately, this is an unavoidable reality - chronic disease doesn’t care about customs and traditions.3

So why am I suddenly reflective? Goodness knows. Perhaps the strange draw of the magic number “10” was too much to ignore (which also makes me wish humans had six digits on each hand – two extra years before considering an article like this). Or perhaps it has been two months since my previous article, and I’m still not close to finishing the series on reporting systems. Whatever the reason, my thoughts have wandered towards the life I had before I became sick, and the one after it.

As a healthy person, I was functionally adaptive. I could schedule changes at the last minute to meet up with friends or do a favour for a colleague. I could stay up late to finish a project or go out to socialise. I was mostly reliable and dependable.

As a sick person, I can do none of these things. But in the past decade, I couldn’t help but notice that the healthy version of me wasn’t completely adaptable.

Stressful dog walks

A curious thing occurs almost every time I am out walking with my mum and our dog. Walking down a wooded path, a person up ahead will see us and stop dead. Arm outstretched, a tight grip on the leash, they will look nervously down at their dog, trying to figure out what to do next. The dog will invariably be lunging towards us, barking or something to that ilk.

If the dog is small enough, the other person will quite literally wrestle the dog up into their arms and carry them past us. A bigger dog, and they will use the leash to drag them as far off the path as possible.4 Meanwhile, our dog is tight to my mum’s leg, no leash in sight, as we both walk past the most confusing examples of human-canine partnerships.

This occurrence seems to be fairly common, as this YouTube video illustrates5:

Reflecting on this after a walk one day, I imagined what dog walking must be like for these people with reactive dogs. The anxiety it must provoke every day. The effort and stress that they must go through for every person they meet on their periodic semi-circular shaped route. Effort and stress which must have knock-on effects in other parts of their life – their relationships, their work. All for what, on the face of it, is not an unsolvable problem.6

Throughout my decade in disease, I have observed this type of inadaptability in friends, colleagues and strangers. I’ve seen countless times where a new member of a group comes in and disrupts the harmony, and instead of the group addressing the issue, everyone gossips in the background while pretending everything is fine in the foreground. I’ve been in situations where someone provides a solution to an individual (requiring a tiny bit of learning) that directly addresses their problem, making their life easier. But, instead, the individual subsequently ignores the suggested solution and continues doing the laborious method they were previously comfortable with (e.g. like manually filling in a spreadsheet instead of learning how to use formulas or macros).

I think that for healthy people,7 this kind of inadaptable “stickiness” is manageable. Yes, walking with a reactive dog is a tad stressful, but once it’s over, one can still get on with the rest of the day. That new member of the group is annoying, but it doesn’t ruin the experience too much. It takes a while to fill out this long spreadsheet, but the work still gets completed to a satisfactory standard.

These kinds of stressors are all manageable. On the other hand, they are also unnecessary. All of them are solvable problems, often without too high a degree of learning. Further, the consequences of a healthy person's inadaptability do not fall solely on the individual exhibiting it. Reactive dogs are stressful for other dog walkers too, newer members of a group may leave because of the unhealthy dynamic, and other people may be waiting on the completion of the spreadsheet.

While healthy people may lose only a small amount of functionality due to these situations, the chronically ill, caught in the collateral damage of someone else’s unintended inadaptability, often collapse into a functionality black hole.

But it might just be the chronically ill, who are the people able to help solve this inadaptability problem.

There is value here, at the bottom of it all

After four years of barely leaving the house with severe agoraphobia, I finally stepped out into the world, fully on my own, in January 2024. By March, springtime, I was taking part in an acting class. By summer, I was in an improv class, and by the autumn I even did a couple of small shows.

Whenever my agoraphobia and anxiety came up in conversation with class members, most were very empathetic, some shared their own anxiety troubles, a few didn’t understand what agoraphobia and severe anxiety were, and one said it was impressive.

I am grateful for the responses I’ve received, and it feels good to have support. Curiously, however, no one asked me how I did it. How I got up on a stage despite finding it difficult to leave the house on most days.8

I think there might be a misconception about the ability of severe anxiety sufferers to deal with anxiety. Such are the levels of anxiety I experience, it often incapacitates me. But this doesn’t mean I am bad at dealing with anxiety. Quite the opposite. In the same way that practising golf every day for ten years means you are probably going to get pretty good at golf, living with anxiety every day has meant I have become (at least in my opinion) pretty astute at dealing with anxiety. In other words, functional inadaptability forced me to become adaptable in the very areas healthy people don’t need to be – emotional and practical.

With a stress threshold the size of a peanut, any way to lessen the emotional and practical burden suddenly becomes an invaluable skill. Over this last decade, it became vital to learn as many viable techniques as possible to recognise when and how stress and other emotional states arise (and how to navigate other people’s stressful and emotional states). I am constantly checking in with how I feel and making decisions based on that. I have planned and experimented within an inch of my life. Finding and testing any possible practical way that could make my life a little easier.9

Mostly, chronic illness forces inadaptability on us as sufferers, in large swathes of our lives. But it can also stimulate adaptability in areas where the healthy are inadaptable. Therefore, there is some value to be unlocked.

As the clock ticks past the decade mark in my time as a chronically ill person, the thing I desire most is to be valued. Without a job, a collapsed social structure, and almost permanent exhaustion, feeling valued would not only help with my recovery,10 I think it would help people in the world of the healthy too.

Most importantly, there aren’t many experiences in life that help with perspective, empathy and desire to aid others as much as chronic illness. It is perhaps the ultimate pyrrhic shortcut to wisdom. It would be a shame for the healthy not to utilise it.

If my meandering musings scratched an itch not too small, consider gifting a❤️ like, it makes me feel ten feet tall.

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I didn’t take this news well. Almost immediately, I collapsed into a non-functional state of pure unstoppable sadness. This had two consequences. Firstly, because I could not shut down the annoying scientific part of my mind – even in a state of distress - interesting thoughts about mental illness occurred. Secondly, it gives me the opportunity1 to provide an update about this Substack. Which I’ll put in this footnote2

A pull towards dysfunction

Compared with a healthy functioning person, my negative mood states have been “sticky”. By sticky, I don’t mean the depressive, everything feels like walking through mud, type of feeling. I mean an implicit characteristic of the negative mood states themselves. Negative mood states have stuck around for a long time.

During the worst period of my illness, I was permanently stuck in several severely negative mood states. Day in, day out. As I have slowly recovered, the “stickiness” of the mood states has reduced. At some point, I managed to achieve a semi-stable euthymic-ish mood state.3 However, even the slightest whiff of stress would knock me right back down into the negative mood states again. This infuriating cycle has continued with a very slow improvement of resilience to stress and reduction of negative mood stickiness.

My recent descent into a negative mood state prompted me to think about the problem I’ve had with this stickiness description. Becoming “unstuck” implies that one cannot return to the stickiness unless an external phenomenon “pushes” you back. In other words, it assumes that stress would be the only factor determining whether I return to a negative mood state. But this has not been my experience.

Even in times of semi-stable mood, I feel a pull, a constant attractive force, towards negative mood states and dysfunction. Like a piece of elastic I can never break free from. All the time, I have to provide some energy to keep me somewhat functional.

When a plane encounters a pothole

A perceived pull towards dysfunction made me think about general relativity. Or rather, it reminded me of my inability to think about it. At best, I have a tenuous grasp of the subject.4 Further, the fundamental problem of trying to communicate how general relativity describes gravity is that it requires the understander to be able to visualise four-dimensional spacetime. Unfortunately, humans did not evolve on a 4D hyperspherical planet.

Space and time (or spacetime) can be thought of as a four-dimensional geometrical structure, a fundamental universe landscape of sorts.5 “Stuff” in the universe interacts with this structure, causing it to bend, which then dictates how stuff moves through it.6 Instead of seeing gravity as a “pull”, it can be (non-)seen as a geometry.7

From this idea of using geometry, or a landscape, to describe a pull, a model of mental functionality started to form in my head.8 To begin with, and I have always wanted to do this, imagine a healthy, spherical human.9

This orbicular person exists on a landscape, simplified to a one-dimensional line on a 2D image, representing the level of functionality. The higher up the line is, the more functional they are, the lower, the less functional (not to scale).10

Our isotropic human usually sits stationary, on the plane of healthy functioning. This plane represents a “normal day” for lack of a better description. Able to cook food, maintain hygiene, socialise, work sustainably etc. The use of energy to perform these tasks is represented by a force that causes a clockwise rotation of the sphere, moving them to the right.11 The winds of stress push the equidistant-surfaced person to the left.12

Ideally, our healthy round-like13 person will conserve enough energy14 to exactly match the force applied by the winds of stress. There is a lot of leeway, however. They can maintain relatively routine functioning despite gusts of stressful occurrences. On the other hand, too many stressors or too little conservation of energy will result in the individual falling into the pothole of reduced functioning - the place healthy people end up when they “over-do” it. An extra amount of energy is required, through rest, to return to the plane of healthy functioning.

Painting a picture of dysfunction in mental illness

My guess is that many healthy people go almost their entire lives with the impression that the landscape of functioning is solid. As solid as the ground beneath our feet. Some may see it as a fact of life – that other people have the same functionality landscapes as them.15

Perhaps the scariest part for the first-time sufferer of mental illness, is learning that the ground beneath your feet can move. Even with the mildest of tremors, the shock can be quite hard to process. I still remember the first time I suffered a depressive episode at 18. Lying awake at night, distressed by an internal reality I did not realise was possible. If only that young kid knew what was to come, how far the ground could fall.

Today, at my current stage of recovery, the situation looks something like this:

I sit in a meta-stable state of reduced functionality right on the edge of significantly reduced functionality – what I’m going to call the “Pit of Crappiness”. Since I exist on an incline, I have to constantly provide energy to stay stable, with or without stressors. I am continually being pulled down towards the crappy pit. Dysfunction in mental illness is attractive.

If necessary, I can temporarily provide more energy to climb further up the functioning landscape.16 However, if I am not careful when travelling back down the curve, I can easily roll off into the pit of crappiness. Therefore, I am forever in a state of managing my condition and navigating stressful events.17

As I recover, the landscape beneath me — the meta-stable “lip” I’m on, as well as the pit of crappiness — is slowly shifting upwards towards the plane of healthy functioning.18 The shift upwards is so slow that I don’t notice it happening. On a day-to-day basis, my functionality landscape usually feels quite solid. My aim is to get as close as possible to the healthy spherical human’s functionality landscape.

Unfortunately, the slow morphing of my landscape upwards is not the only way my landscape changes.

If I spend a long enough time in the pit of crappiness, or face a significant stressor,19 I go over a different type of tipping point. The ground beneath me snaps and shifts suddenly, like in an earthquake. And I then find myself plummeting towards, what I will call, a functionality black hole.

Astronomical black holes

Black holes are the places in the cosmos where the universe accidentally ran into a system error but decided to keep the game going anyway. Born from the gravitational collapse of a dying star,20 black holes are objects with centres of infinite density, otherwise known as a gravitational singularity.21

Flinging yourself into a black hole would be the epitome of a poor life choice.22 Even if you paid for the premium supermassive black hole experience, thus avoiding public spaghettification,23 let’s just say there would be no need for a return ticket. Below a certain radius, otherwise known as the event horizon, not even spontaneously turning yourself into light would save you from your inevitable journey to the end of time and the central singularity.24

Despite its name, events do occur beyond the event horizon, we just can’t see any of them. In fact, as you were falling into the supermassive black hole, you wouldn’t even notice your last mistake. Unfortunately, the entire universe would be able to see you about to commit your blunder for a very long time. To a faraway observer, you would move slower and slower, looking redder and redder, as extreme time dilation began to take effect, before you finally froze right on the edge of the event horizon.25

Functionality black holes

Falling into a functionality black hole looks a lot like falling into an astronomical one. To an outside observer, I look as if I am doing less and less, before I seem to stop functioning completely. On many occasions, outside observers have suggested I try something or other to rectify the situation. To them, it appears that escape is still possible. They don’t realise I have already crossed over the functionality (event) horizon.

In my head, I am fighting to reduce the speed of descent as much as possible. As an explosion of emotional and mental pain bursts forward from the depths of my mind, I must spend all my energy rotating my little spherical being as much as possible. I resort to the fundamentals: eating, sleeping and distraction.26

Below the functionality horizon, the gradient is too steep to escape. It does not matter how much energy I conserve, how many cognitive tactics I implement, or self-care I try to carry out. I will stay dysfunctional. It feels as if all paths lead to a singularity of infinite dysfunction. It feels like I will stay in a dysfunctional state for the rest of my life. The certainty of this feeling is difficult to describe.

The only way out of a functionality black hole is to trust that the ground beneath my feet will eventually change back to the pit of crappiness.27

Sometimes, however, time doesn’t heal all. Not on its own. For a couple of years, I was stuck deep down in a functionality black hole. I had to find treatments, in my case medications, that would force my functionality geometry to change. I was lucky to find treatments that helped.

Many aren’t so lucky. For example, some people with chronic fatigue syndrome (CFS) and/or Myalgic Encephalomyelitis (ME) are tragically stuck beneath the functionality horizon, unable to escape the functionality black hole, with no treatments available for the foreseeable future. Many worry they will spend the rest of their lives never to see the light of functionality again.

Ultimately, I don’t know

I don’t really know how to finish this article. I first thought about trying a description of how I feel about my dog. But one becomes very superstitious in this particular scenario. Every wording I tried felt like I was tempting fate. Then I thought about attempting to write something deep about black holes relating to life and stuff. But it was vague and ended up as one of those passages that feels like it is describing something profound, but in reality, wasn’t really saying anything at all.

Perhaps then, it is quite fitting to end with a huge “I dunno” shrug. We don’t have an experimentally proven quantum theory of gravity, which means, ultimately, no one really knows what happens past the event horizon of a black hole.

In the same vein, while I’ve tried to come up with rudimentary, poorly drawn diagrams of what I think might be going on in my head while in a period of low functionality, ultimately, I don’t know if it resembles anything close to what is actually going on.

A sad end to an article starting with sad news.

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Many future Psyverses will be based around the theme of medical mistakes. Psyverse #2 will be specifically about how independent national voluntary reporting systems, used in the aviation industry, could be applied to the psychiatric system. Before we get there, however, I thought I would tell you the story of my severe reaction to an antidepressant. And the many mistakes that were made.1

Mistake #1 may have been the advice from my GP to take an antidepressant. It was late 2015, a year into my PhD. An unfortunate series of events had sprouted blackened vines of depression, dragging me deep into dysfunction. In a desperate bid to escape, I tried meditation, eating healthily, exercising, quitting drinking, and university counselling. In my head, I thought taking an antidepressant was the last remaining option. I did not know that other forms of counselling existed. I didn’t know psychotherapy could go on for longer than six sessions.2

I was prescribed the SSRI3 Sertraline at the starting dose of 50 mg once daily. On the first day, I experienced the typical side effects: slight worsening of depression, a little nausea and a lack of appetite. During the second and third days on Sertraline, numbness replaced depression. It was strong. So strong that stressful events like going to a restaurant with my mum and disabled sister, with the accompanying glares, ceased to influence me. I thought this was brilliant (well, a fuzzy version of brilliant). I could return to my normal life.

After the fourth 50mg dose, I felt an “energy” build inside my head while washing dishes. Overcome by a strong urge to find safety, I dropped a half-washed dish into the sink and rushed to the sofa. A few seconds later, I snapped into the foetal position.

A violent tremor spread through my limbs, torso, and head, growing stronger with each moment. A viscous, lava-like ooze expanded outwards from the centre of my brain. It felt physical, like a real substance swallowing neurons. Just before it captured my outermost brain matter, I closed my eyes and waited to die.4

My first thought when I opened my eyes was, “Oh good, I’m not dead!” Shock, as I found out, affects different people in different ways. My version was not running around like a headless chicken, or sitting stationary in frozen silence. I moved mechanically in eerie calm. The only thoughts that occupied my mind during the next few hours were related to figuring out what on earth had just happened.

In conversation with my mum on the phone, we determined that I had just experienced a panic attack. We were wrong. Before that day, I had never experienced anything close to a clinical anxiety symptom. Therefore, I had no frame of reference.5

The next mysterious definitely-not-a-panic-attack jolted my eyes open during deep sleep. Due to the unnerving disorientation of waking up in the middle of one of these realistic nightmares, I cannot say for certain if it was worse than the first attack. It was at least just as bad.

My legs were shaking so violently this time that I became physically unable to walk. To pass the time, I grabbed my phone from the bedside table and rang the NHS 111 service.6

The person on the other end of the line instructed me to go through the checks for a stroke. Arms in the air, etcetera. When I passed these checks, they advised me to go back to sleep and call the GP in the morning. Then they hung up. This was Mistake #2.

I looked down at my still-shaking pair of legs. “Ah”, I thought, “probably should’ve led with the whole non-functioning legs thing”.7

There was no way in hell I was going back to sleep. After waiting fifteen minutes to gain control of my legs again, I gingerly hobbled to my housemate’s door, woke him up, and asked if he could give me a lift to the hospital. He did, no questions asked.

By this point, I had figured out that I was experiencing something worse than a panic attack. But this meant I didn’t have the language to describe what had happened to me. When I reached the front desk of the hospital emergency department at around 1 am, I picked the closest condition I could think of: “I think I’ve had a seizure…”

The receptionist asked me to take a seat in the waiting area as the nurses were all busy. I turned to see around fifty empty chairs. I didn’t give it a second thought. In an underfunded and understaffed NHS, I believed the receptionist.

“If this was a seizure, you would have choked on your tongue” a nurse opined ten minutes later. Mistake #3 was a doozy. Part one was pre-judging me as a patient before I gave her a proper patient history. Part two was making the egregious error of assuming all seizures were Tonic-Clonic.8 I didn’t know at the time, but there are many types of seizures that present in many different ways.9 For instance, in some types of seizures, like myoclonic seizures, sufferers usually don’t pass out.10

The nurse proceeded to make Mistake #4. She told me that getting on to antidepressants was tough; I needed to get through the initial side effects before the medication would start to work.

I saw a resident doctor next who asked what had happened. I told them a shortened story, along with the symptoms I suffered, to the best of my ability. The doctor started a typical series of tests. Most came back pretty normal.11 Then came the knee reflex test.12

As a naïve 23 year old, I had no idea what a “normal” reflex was supposed to look like. So, when I nearly kicked the resident doctor in the face after a light tap on the knee, I commented like an enthused child “Wow, it’s crazy how strong reflexes are!” then produced a dumb smile. She did not smile back.

Instead, I saw a deeply concerned glare directed at my knee. My face dropped immediately. After testing other reflexes on my body, producing similar limb-propelling results,13 the resident – with the once joviality in their voice changed to stern seriousness – stated that they needed to talk to the attending doctor and quickly exited the room.

The attending made Mistake #5 by not quickly rechecking my super-reflexes. Mistake #6 soon followed in a mostly one-sided conversation. “It is most likely just anxiety,” the attending remarked (paraphrasing). If the attending had taken a patient history, they might have realised that before taking Sertraline, I had never experienced a clinical anxiety symptom. At the very least, by allowing me to speak, they might have noticed my strange calmness.

I was sent home with a second occurrence of Mistake #3 – to keep taking the Sertraline. As this was a separate, independent incident, I’m calling this Mistake #7.

All the clinicians I saw that night made Mistake #8 – a missed symptom. A day or so later, my mum noticed my eyes juddering side to side. Ocular Clonus.14 Her brother had nystagmus15 growing up, which is why she spotted it.

Within a couple of hours, seven mistakes were made by four different clinicians. Quite the astonishing statistic. Each failed to recognise a potentially life-threatening syndrome. Unfortunately, this was not the end of the mistakes.

When I arrived home, I did not know whether I should take the next Sertraline tablet. My feeling was no, given the severe reaction, and I had already decided I was going to halve the next dose. But two clinical professionals had advised I continue. I wasn’t a doctor, and I knew my brain was in no state to make such an important decision.

I decided to call the university counselling service. I wanted to talk with my counsellor - someone I thought would be neutral. The administrator picked up the phone. They explained that it was not university policy for students to talk with counsellors outside of booked appointments. Through tears, I pleaded with the administrator to please give me two minutes, I could wait for a few hours, just two minutes. “No” was the response. But they could email me an e-leaflet containing strategies to deal with anxiety. “Okay”, I said dejectedly, and hung up. The first tip of the e-leaflet was to do a relaxing activity, like reading a book. I deleted the file.

Mistake #9 was soul-crushing. In my hour of need, the university counselling system was absent. Those two minutes could have been more helpful than the entire six-hour appointment structure.16

In the end, after talking with my mum, I decided to come off the Sertraline. When I rang my GP to inform him of my decision, I was asked three or four more times “Are you sure you don’t want to stay on the antidepressants?” Mistake #3 a third isolated time – which makes it Mistake #10. At every point throughout this story, I felt like clinicians were willing me to stay on the SSRI.

If I had listened to any of them, there is a possibility it would have resulted in my death. The signs and symptoms pointed to a serotonin syndrome – albeit a strange and rare case.17 Serotonin syndrome occurs when there is too much serotonin in the brain. It can be deadly. When John Mayer sings “I’ll be dreamin’ of the next time we can go into another serotonin overflow” in the song “Love on the Weekend”, he is either singing about a suicide pact or doesn't quite understand the ins and outs of brain chemistry.

I was experiencing mild to moderate symptoms, but had I continued to take the Sertraline at the same dose, one can imagine things becoming serious quickly.18

At the end of our conversation, my GP rounded off one of the most stressful and horrifying experiences of my life with Mistake #11. He confidently told me that once I came off the SSRI, the symptoms I was experiencing would disappear. I was relieved. For a few days.

The symptoms, while abating a little bit, did not disappear. In fact, some new ones arrived. For instance, severe panic attacks and hypochondria, and, well, it is easier to copy in the list I made at the time with the symptoms I was left with. I had experienced none of the following before taking the Sertraline19 :

• Nausea

• Palpitations

• Pupil dilation

• Dizziness

• Confusion

• Violent Shivering

• Sweating without cause

• panic attacks (approx. 10 per day)

• occasional very severe Panic Attacks20

• difficulty concentrating

• anxiety attacks (very frequent and spread throughout the day

• loss of balance

• Twitches/facial tics

• “Brain Zaps”

• Numbness (extremities mainly)

• Hypersensitivity

• Hypochondria

• Insomnia

• Headaches of varying types (Dull, sharp and short, tension)

• Sharp pains all around the body (randomly come and go - they would trigger brain zaps)

• Diarrhoea

• Visual “fireworks”

• Hyper-reflexes

• Raised blood pressure

• Shortness of breath

• Fatigue

• Doom feeling and dropping sensation (associated with balance and anxiety attacks)

• Weakness in legs

• Restlessness

• Decreased appetite

• Emotionally and mentally all over the place

• Depression

• Generalised anxiety

And so began a six-year battle to find treatment.

During those six years, the mistakes did not end. It took six months for the serotonin syndrome to finally be diagnosed. I was prescribed Venlafaxine, an SNRI, ignoring a warning in my medical record that it should not be prescribed.21 In a care plan, my fourth psychiatrist rewrote my history based on a fifteen-minute phone call.22 I was given ten official diagnoses – only three of those were related to my condition. In Psyverse #0, I mentioned perhaps the biggest mistake of all, not diagnosing me with generalised anxiety disorder despite having clear symptoms. The most common mistakes were logistical and administrative errors. My lithium treatment was delayed by 42 days, mostly through administrative mess-ups.23

My story is not unique. In medication errors alone,24 it has been reported that an estimated 237 million occur every year in the UK.25 Most of these, around 75%, are estimated to cause no harm to the patient - many are caught before they even reach the patient. An estimated 2% have the potential to cause harm,26 with approximately 22,303 contributing to deaths.27

The number of patients who die each year from medical mistakes is a controversial subject. It has been significantly overestimated in the past. In a 2013 Manuscript, it was claimed that 440,000 deaths due to preventable adverse events occur annually in the United States. This was followed by a 2016 commentary which claimed 251,454 deaths by medical error per year, making it the third leading cause of death in the United States. The 2016 commentary was widely reported in news articles and widely referenced in the academic literature. Unfortunately, both of these statistics were unfounded.28 The actual figure is probably around 25,000 deaths by medical error per year in the US.29

But from my experience, focusing on mistakes causing direct harm misses the point. A much greater problem is the lack of trust created by “non-harmful” mistakes. Every time a clinician did not know what medication I was on, an administrator did not pass on the correct information, or my medication was prescribed with incorrect instructions, trust was lost. I became paranoid not because of my anxiety condition – paranoia was not there at the beginning – but because of the additive nature of the small mistakes I kept experiencing. I knew that one of these mistakes could cause me harm.30

Loss of trust between patient and practitioner means a loss of communication. I started to withhold information and accentuate certain symptoms to get the treatment I needed. To be clear, I didn’t start out this way. I started out as honest as I could possibly be. But when the honest information I provided led to misdiagnoses, misunderstandings and mismanagement, acts by clinicians became a threat to my health. The mistakes led to the expectation of a lack of competency.

As I will explore, there are many reasons for these mistakes occurring. There is no simple cause. In fact, health services have improved patient safety dramatically over the last twenty years. Nevertheless, the medical field is still playing catch-up. We are not near the end of the road yet.

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I fought hard to keep my social network in place. But once mental illness takes hold, friends disappear quickly. I am still shocked at just how easily I was forgotten by most of my friends. I kind of get it. Mental illness is a scary thing to be around. I couldn’t communicate how much scarier it was for me.

So, while I find myself in the extraordinarily lucky position of finding a treatment that is slowly reducing my anxiety symptoms, I also find myself with very few friends to speak of. The situation is improving – but these things take time.

The limited ability to attain feedback is not exactly at the top of my list of “problems of not having friends” but in the context of Substack, it is relevant!

It also doesn’t help that I’ve fallen into strange psychological irrationalities. It seems that the riskier the article, the greater my fear that it isn’t very good, the less I want to reach out for feedback. So, I release it to the public instead un-feedbacked. This makes no sense whatsoever.

The most prominent feeling I’ve felt after publishing the two Psyverse #1 articles is embarrassment. My previous guest posts were all serious critical analyses, and suddenly, here I am launching into moth-people with no context whatsoever. From the little feedback I’ve had so far, it seems most people are confused. But without knowing more detail, I am not sure how to fix it for future posts.

While I feel a bit vulnerable asking you so openly for feedback, I feel like this is the logical thing to do. I haven’t really seen other writers on Substack publicly ask for feedback (other than for topic suggestions). But I don’t have the friends or colleagues to provide feedback for this article about asking for feedback. I am stuck in a lack of feedback loop.

So, if there are readers out there who would be so kind as to tell me what they thought of the Psyverse #1 articles, I would be grateful. Rather than public comments, I’d appreciate a direct message, or email (see here).

To help, I’ve put the main message I wanted to convey in Psyverse #1 in this footnote,1 some of the questions I have in this footnote,2 and some of the reasons why I wanted to start the psychiatric multiverse in the first place in this footnote.3

Thank you to those who will take the time to write feedback on the Psyverse #1 pair of articles – it is much appreciated!

Part one:

I am hoping that the creation of absurd alternate universes will help the discussion of ideas, reducing the friction between opposing viewpoints. I’ve noticed that when we present ideas within the context of our own universe, it can feel very personal to those who disagree - sometimes almost to the point of insulting. Angry responses produce angrier replies as discussion descends down the attractor of rage. Whereas when an idea is presented within the context of an already absurd premise, I hope it will become much harder to become angry. Affronted criticism can be instantly met with “Um… dude… we are talking about an earth entirely inhabited by moth-people.”

This is not to say I wish to completely avoid criticism. Quite the opposite! I am hoping to encourage discussion, whether through comments, DM’s, Substack notes, etc.

"There are women sitting in the front row!" I thought in exasperation. On the stage was a not unattractive bespectacled man in the middle of explaining all the different ways women had mistreated him while dating. He talked about ghosting and lack of commitment, amongst a list far too long to be remembered by the author. He then told a joke about how women should stay in the kitchen. For a brain in a state of confusion, it was surprising how clearly he managed to communicate to the audience the real reasons behind his "misfortune" in dating.

He was supposed to be telling a story, but it better resembled a cross between a rant and an advertisement. Throughout, he mentioned his new book outlining how he thought women should behave while dating a man. You really couldn't make this stuff up.

Well, apparently, he could.

Misogynist man was the first of three "story" tellers I endured during this non-Moth storytelling event. It was independently organized by a local businessman in the town where I lived. Moth storytelling events in the United Kingdom are only held in London, once a month. For me, it was at least an hour and a half journey each way. I thought this little independent local storytelling event would be a similar experience - I was wrong. Oh, I was so very wrong.

The second storyteller trudged onto the stage1 with the energy of a substitute teacher who had missed their morning coffee. She was tall and slender with shoulder-length blonde hair. I would tell you what her face looked like, but unfortunately, it remained hidden behind a sheet of A4 paper. “I’m going to read you a blog post about my adventures in the United States” she declared in a monotoned voice. I was hoping for a story like “Thelma and Louise”. It was like Thelma and Louise, if Thelma had gotten into their car, driven to a petrol station and gone home. Because that was pretty much all that happened in her story. Driving. Down a road. For fifteen unbearable minutes.

The third storyteller decided that stories were beneath her. She came dressed in a long flowing skirt, no shoes, and dandelions knitted into her hair. "She's going to read poetry, isn't she..." I said to my friend next to me. Before he could answer, she started reading poetry.

About two lines in, she ran out of words that rhymed with "San Francisco". Instead of using a thesaurus, she came up with the ingenious idea of rhyming San Francisco with itself. Funnily enough, the poem wasn't even about San Francisco. "Each poem costs 1 pound" she said proudly once finished. "Let's get the heck out of here" I whispered to my friend. We left at the intermission.

Spark Stories and proper storytelling

While demoralised, I had not given up hope. I decided I would go to a proper storytelling event in London. It wasn't an official Moth event but was very similar to it - Spark Stories.

At the beginning, the host gave a short introduction, going over the do’s and don’ts of telling a story. Storytellers had only five minutes to tell their stories; there was no opportunity to meander. You weren’t allowed to read from a script or notes. The stories had to be true and personal—the storyteller had to have first-hand experience of the story they were telling. A warning was given to avoid going into a stand-up routine. This structure geared the storytellers toward producing authentic stories.

I had no intention of telling a story, but the organisers persuaded me to have a go. While telling a story with zero preparation wasn't ideal, I was surprised at how much the structure helped. It was a completely different dynamic compared to the horror show I experienced at my local storytelling event.

At the end of the Spark Stories event, a magical thing happened. Talking to new people was easy. No confidence or energy was required. In fact, I felt compelled to talk to other people. The short, true and personal stories became the perfect icebreaker. Instead of the energy-depleting awkwardness of small talk meanderings like “What do you do?” “Where are you from?” “That’s a nice bracelet”, we were all away. It was a wonderful experience.

I eventually did manage to go and see a proper Moth storytelling event. It was a bit more of a show and less intimate, but the principles remained the same. At the Moth, storytelling was the focus. There were no long introductions or numerous titles attached to the storyteller’s name. No money changed hands from organiser to storyteller. There was no agenda. The aim was authenticity. The result was an experience that satisfied my primal urge to connect.

Why did the setup at The Moth and Spark Stories result in an urge to connect? Well, I think the removal of ulterior motives in combination with the restrictiveness of the rules encourages the storyteller to be vulnerable. This signals to the audience that it is okay to be vulnerable too - to let down the guardrails. I think the audience then starts to feel similar emotions to the storyteller, which can evoke similar personal stories. Once the event ends, the need to reciprocate a personal story is so strong, an audience member feels compelled to reach out to the storyteller and other listeners.

In other words, instead of connecting on ideas, storytelling events encourage people to connect on deep emotions. The trivialities of things that normally keep people apart, like politics or ideologies, cannot reach this place. It is superceded by deep emotional connection.

Since attending these storytelling events, I’ve often wondered what the world would look like if events such as Spark Stories or The Moth had become commonplace. I started to construct an entire universe within my mind.

Storytelling in Psyverse #1

In Psyverse #1, storytelling events are so abundant that they are not seen as events but as a social experience, like having lunch with a friend or going down the pub or bar for a drink. The Moth-people in this universe gather at the end of the workday, or at the weekend, and tell stories.

Friendships and relationships are deeper and more resilient. Moth-people are prepared to be more vulnerable, more willing to connect, and more able to relate to one another. There are still arguments and fights, friendships still come and go, relationships still end. But when the opportunity arises to form a deep connection with another person, Moth-people grab it with both hands, instead of passively watching it go by, like a shadow at dusk.

Perhaps unexpectedly, Moth-people are much more productive at work. In our universe, there are countless articles proclaiming the one true method or technique that will immeasurably boost your productivity. I observed during my PhD, however, that the greatest cause for a loss of productivity didn’t seem to have anything to do with a single method or technique. It was the absence of emotional connection that drove wedges into the cogs of workplace productivity.

The flaw of productivity hacks is that they mostly focus on the individual. But companies and institutions generally need people to work in teams. Since the colleagues around me saw each other mostly through titles,2 many would be worried about going to someone if they had a problem. They were worried about making mistakes. My peers would often complain and gossip to other employees instead of engaging with the colleague they had friction with, to let them know it existed.

The Moth-people of Psyverse #1 often socialise at work through the storytelling setup, both formally and informally. This means that most colleagues have at least one personal connection between each other, unrelated to work.

When I think about the importance of relationships in the workplace,3 I think about Starling Mumurations.4 During the winter, starlings visit the UK from the European continent. On the odd lucky occasion, I have seen large flocks of these birds moving and shifting, as if they had one mind.5

But this is an illusion. In reality, starlings self-organize. Each starling only keeps track of its seven nearest neighbours.6 When one of its neighbours moves, the starling has to move to adjust. For a murmuration to function, every starling has to be intimately connected to the movement of its neighbours. Relationships between individuals allow a group to move as one.7

Alex finally gets to the point

As a patient, the most disappointing thing about reading some of the psychiatric discourse is the bickering. The endless ideological attacks between some psychiatrists. This type of discourse is so far removed from the realities of patient care, I cannot help but feel hopeless about the situation. Thomas Reilly eloquently sums up an example of an ideological battle between the psychiatrists Joanna Moncrieff and Nassir Ghaemi in his article: Our blessed science (their barbarous pseudoscience).

While you might strongly agree or disagree with Ghaemi and Moncrieff’s positions, it is important to recognise they are human. They both have worlds outside of psychiatry with deep personal stories that readers might relate to. But we never hear these stories. There is no current social structure in place to tell them.

Between our two universes, it was the moth-psychiatrists that gained the most relative benefit. Storytelling helped moth-psychiatrists find common ground with each other, separate from their viewpoints. There are no moth-anti-psychiatrists. Storytelling events facilitated personal connections; moth-psychiatrists don’t see each other as enemies. They don’t simplify their mothanity to a philosophy or specific viewpoint. While nurturing their own individual theories and ideas, moth-psychiatrists still move as one, like starlings.

Psychiatrists in our universe routinely see patients in distress and, in an underfunded mental health system, are some of the busiest people I have ever come across. Burnout is prevalent,8 and it is not known how many psychiatrists suffer from mental health conditions themselves.9 Storytelling events help moth-psychiatrists create the close relationships and support networks needed in such an environment.

During my time in the psychiatric system, I have felt like a patient and nothing more. I've never wanted a psychiatrist to be my friend, but I would've liked to have been valued for something other than the disease I carried. Because of storytelling events, moth-psychiatrists understand that a small external connection with a patient helps immensely with communication and trust.

I think physicists in our universe could benefit from personal storytelling events too. But for different reasons. I think many of us struggle to express our emotions, which means there is a significant mental health problem within the academic community.

Nevertheless, I believe physicists manage to leverage creative non-fictional, non-personal storytelling better than most other groups of people. Physics is so weird, so absurd, trying to understand and then communicate concepts within it requires imagination.10 Randall Monroe and his “What If” book series exemplify this type of storytelling. If psychiatrists want to become more imaginative, they must become courageous enough to engage with and tell absurd stories.

Stories form the core of who we are as people. Religions are built on stories. When we meet up with friends for a coffee, we tell stories. When we sit around the dinner table, we tell stories. But, in modern life, storytelling is always the secondary focus. When it is the primary focus, like in a book, TV show, film or play, the stories are made up. Fictional. One of the, if not the only, avenues to tell a personal story to strangers in modern-day life is through a memoir. Which by its nature, is an isolated activity.

This does not mean I am imagining a universe where everyone is “like a family”. I'm saying that having one or two emotional connections with the people you work with, you play a sport with - whatever group you happen to be a part of - might help everyone communicate better and perhaps even live happier lives. I wonder what the world would look like if everyone had that one percent emotional connection with each other, to be one percent Moth.

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5

See video, or gif here:

For pretty much all the articles I have written up until now, I’ve had to reign in my tangential mind. My brain seems to like making connections between things which appear unrelated but are actually linked in an unexpected way. This seems like a cool ability on the face of it. Unfortunately, it is only around 5 – 10% efficient. Much of the connections I see aren’t really there. And sometimes I miss connections between things which are obviously related.

Given I am my own editor (I’m not sure whether this is a good or bad thing yet…) I’ve let my tangential brain free. This has two consequences.

You might often be wondering, “What on earth has this got to do with psychiatry?” By the end of this two-parter, you might, quite rightly, question why I didn’t just get to the point immediately. I guess my answer would be that I wouldn't be able to write the end if I didn’t write the beginning. I find a particular joy in the journey. Of telling the interesting stories that many of us miss in the hustle and bustle of everyday life.

The second consequence is footnotes - a lot of footnotes. A lot of interesting and detailed footnotes. I am aware that for some people this might be distracting – if so, I’m willing to post footnote-free versions somewhere else. Just let me know in the comments!

On to our first Psyverse…

Quite why the human-like inhabitants of Psyverse #1 had feathery antennae growing out of their foreheads was anyone's guess. The most popular theory in mothiety was that a radioactive moth bit a human ancestor - thus fusing their DNA.1 This theory first came to public attention after an Egyptian Hieroglyph displaying a muscular moth-like person fluttering mindlessly towards the moon2 was shared via social media. It certainly did not help that the film "Spider-mothman" - about a teenmothager who becomes a superhero after getting bitten by a radioactive spider - came out around the same time.

The Mothosapiens with common sense liked to point out that hieroglyphs "are not literal depictions of reality"3 and that "Spider-mothman is just a dumb film", but what do they know? Unfortunately, just like in our universe, common sense was a rather scarce commodity.

Most of the scimothists focused their attention on more plausible theories. The general consensus as to why every human had a pair of moth-like antennae was due to something called "convergent evolution". This is where distantly related organisms evolve similar looking features or exhibit similar behaviours. In other words, nature occasionally likes to reinvent the wheel.

For some reason, our earth in our universe is perfectly set up for crabs. So much so that there is a specific term for organisms that evolve crab-like features: Carcinisation. Psyverse #1, on the other hand, seemed perfectly set up for moths. Mothinisation4 had occurred in so many species, scimothists knew that there must have been something advantageous about the moth-like form - antennae in particular.

If the scimothists were inter-universal beings like you and I - free to wander around the psychiatric multiverse - they would quickly pick up on the fact that their universe had a lot more "stuff" in the air.

Earth in Psyverse #1 was almost in a permanent smog of chemicals.5 The furthest you could see, even with the extraordinary eyes of a bird,6 was about 10 metres. In nature, when one sense starts to become not very useful, its function diminishes.7 Therefore, the moth-people of Psyverse #1 had remarkably poor eyesight. Where’s Waldo (or Where’s Wally if British), a fun children’s game in our universe, is one of the most difficult sports to play in Psyverse #1. They even have World Championships, where, like many first-time watchers of ice hockey, most moth-fans have no idea what is going on.

Moth antennae8 are very sensitive to smell. Male moths are able to detect a single molecule of a female’s pheromone using their antennae and can follow these scent trails for several kilometres.9 In fact, some researchers have even developed a “smellicopter” that uses real moth antennae to navigate a drone using chemicals in the air.10

Scimothists proposed that the reason for the abundance of moth antennae in Psyverse #1 was because of the ability of moth antennae to pick out tiny concentrations of molecules in a diverse background of smells. Which could then be used like “sight” in a similar way dogs use smell to “see” in our universe. Why not noses? Who nose? Bu dum tsh... (Sorry).

Whatever the reason for the feathery protrusions emanating from people’s foreheads, moths became an important symbol of Psyverse #1 culture. So in 1997, when the moth-like version of George Dawes Green held the first storytelling event called "The Moth" in his New York living room, the relatable idea took off all over the world. Storytelling became part and parcel of modern day life.

Yeah...so...erm... Psyverse #1 is not about moths. It's about stories...

As common as going to the bar or pub, grabbing a cup of coffee or watching a film (I've heard Spider-mothman is quite good at the moment), moth-people would go to storytelling events. In Psyverse #1, they are held everywhere, from the biggest cities to the smallest towns.

The setup is relatively simple. A theme is selected for the night in advance - for example, this could be "Love hurts". Storytellers can interpret this theme however they see fit, which is part of the fun. Anyone attending can then drop their name into a hat to sign up to tell a story. Names are then drawn. Those lucky enough to be chosen are invited onto the stage to tell a five-minute story. The story has to be true, it must be on theme, it must have stakes, it must be personal, and it must be on time.

Due to its popularity, moth-people in Psyverse #1 are far less lonely and have stronger friendships than people in our universe. The most significant difference, however, is the strength of the communities. Storytelling helped form emotional bonds outside of tribal identities. The introduction of storytelling events in Psyverse #1 was so powerful that it transformed moth-psychiatry from a fractured collection of ideologies into a unified, patient-centered practice. Perhaps the same could be achieved here…

To be concluded in part two

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This is, in reality, a misnomer. A recent paper in Nature has provided experimental evidence that moths and other insects are not attracted to light at night, but instead are “captured” by it. Supposedly, moths use moonlight, and light in general, to dictate which way is up. So they will always turn their backs to the light. Moths that fly by an artificial light will “orbit”, “stall”, or “invert” around it.

It is all rather sad. But a reason to ensure that streetlamps do not “leak light” in directions other than down.

On the upside, an algorithm inspired by this behaviour, called Moth-Flame Optimization, has been utilised in many areas of computer science, from forecasting the electricity consumption of Mongolia to terrorism detection.

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I have no idea if birds can see any better through smog than any other animal’s eye. But birds’ eyes are incredible.

Firstly, they are deceptively huge. As they are not spherical, they extend deep into most birds’ skulls. This allows a large field of view, a large picture from all the light coming in:

The visual acuity* of Hawks and Eagles is so good that they could do an eye test from across the street (assuming linear distance acuity). They have an acuity of 20/5, meaning that assuming you had normal healthy vision, you would have to stand 5 feet from the letter chart (or Snellen chart) to just about make out one of the lines of letters, while an eagle could make them out from 20 feet.

This is before we even get on to colour. Some raptors have four “cones” instead of the three humans have. The fourth absorbs wavelengths in the UV range - yes, some birds can see UV light alongside the other colours we mere mortal humans can see (and birds also have a higher density of cone cells, thus allowing a wider colour contrast range*).

*Acuity is being able to see minute detail of a very small object on a highly contrasted background. Contrast is the ability to detect boundaries of objects with similar coloured backgrounds. See here.

Here are some additional interesting sources:

A) Eagle Eye wiki
B) Why Bird vision is cool
C) Visual Acuity wiki
D) High colour vision resolution but low contrast sensitivity in raptors

So, building a backlog of articles took a little longer than I thought. There were tons of interesting topics, and I now know way too much about horses. Anyway, we have finally arrived. Thanks for being patient!

Within the Local Galactic Group of the Virgo Supercluster, on the Orion spiral arm of the Milky Way galaxy, lies a pale wine-dark dot.1

Our pixel in the universe is home to a curious group of humans called psychiatrists. If you were to ask any psychiatrist where they thought psychiatry’s place in the universe was, I guess many would respond “We don’t even know psychiatry’s place in psychiatry”.

Psyverse #0 is our universe, our earth, our home. Here is where you will hear one psychiatrist advocating passionately about the efficacy of a certain treatment, while another completely disparaging it. Where some psychiatrists present themselves as experts on pretty much everything, and for others it can be unclear if they are experts on anything. It is on our planet where psychiatrists dizzy themselves in circular arguments about what is brain, and what is mind. And this is before we even get to the “anti-psychiatry” movement.

I'm not sure many within the field of psychiatry appreciate how incredibly odd it is to have a group of psychiatrists and patients who identify as "anti-psychiatry". Do any other medical fields have such a curiosity? Are there anti-cardiologists or anti-ophthalmologists? I don't think there are, but I claim overwhelming ignorance of these things. I do know that when scientists in my field mention "anti-matter physicists,” they are not describing fellow academics with a general dislike of matter.

In the swings and roundabouts of psychiatric discourse, it is difficult to find any common ground. There is too much on the line, too much skin in the game. It is likely some, if not most of you, have seen how destructive even the mildest of mental illnesses can be to the life of a sufferer. Never mind the bone-chilling suffocation of severe conditions. I am certainly not immune to the bias caused by personal experience.

I think it is fair to say that my experience of the psychiatric system has not been a wholly positive one. To start with, the circumstances under which I attained the conglomerate of chronic severe anxiety conditions I suffer from were often not believed by most of the clinicians I saw. Having never suffered a clinical anxiety symptom in my life, four days after starting an antidepressant, I had pretty much all of them.2 A severe reaction (a serotonin syndrome) on the lowest dose changed my life forever. Convincing any psychiatrist this was in fact the case proved to be mostly impossible. "Serotonin syndrome is an acute condition", many a clinician has explained patiently to me.

I know it is acute! When a medium strength typhoon blows through Tokyo, not much damage is caused. But if one were to turn up in Stockton on Tees,3 well, the town would get quite a severe semi-permanent makeover - and not in a good way.4 The pertinent question I wanted answered, but no psychiatrist asked, was: why was my brain like Stockton on Tees, rather than the Tokyo brains of other serotonin syndrome sufferers?

It subsequently took 6 years for a treatment to be found which started to reduce the symptoms of my Generalised Anxiety Disorder (GAD). The predominant reason was because I was never diagnosed with Generalised Anxiety Disorder.5 I'm still trying to figure out quite why. One psychotherapist even got annoyed when I couldn't be specific about my anxieties: "But what specifically are you anxious about?" she said. "I guess, everything outside?” I replied, “Though I'm not sure that counts as specific". "But what in particular?" she persisted. I sighed in frustration.

Had any clinician recognised my generalised anxiety disorder and followed the British National Formulary (BNF) guidelines6 for medication therapies of GAD, my condition would have been treated approximately 5 years and 11 months earlier.7

This I would not describe as an efficient process.

As you can probably tell, there is still quite a bit of anger in me about how things have turned out. But I think even the saintliest person would feel some injustice living with the knowledge that at least six years of abject suffering and misery could have been avoided.

Nevertheless, to categorise the entire psychiatric system as awful is neither true nor useful. And I don't want to be angry all the time. For the Psychiatric Multiverse, I want to go back to one of the reasons I became a physicist in the first place - the exploration of absolute absurdity.

Psychiatric discourse can often feel very serious. And for good reason. Mental illness is one of the few collections of pathologies that can kill at any stage. Even mild depression can still feel overwhelming enough for someone to go against their most primitive of instincts: survival.

Psychiatrists are trying to treat what is arguably the least understood organ of the human body, with little to no available information about it. There is a reason you will find that psychiatrists almost never run a blood test - there are currently no reliable biomarkers that indicate a relevant disease state.8

I'm not sure you would find a much better example of a "tough gig". In such circumstances, it can become easy for ideas to be ingrained. Static and still. I hope the Psychiatric Multiverse will help evoke the emotion that combats stuck minds: curiosity. As the psychiatrist Dost Öngür puts it while talking to Awais Aftab:

There is a lack of imagination in our field. It was probably necessary for psychiatric science to mature by becoming institutional, developing its own dictionaries (such as the DSM), and establishing shared terms and references. But these do not amount to a scientific paradigm; they are simply a set of concepts and practices that we inculcate in each new generation of researchers. And these concepts and practices narrow the scope of questions that are asked and explored. No need to get philosophical about this; suffice it to say that it is rare for me to read a newly submitted manuscript and think, ‘This is clever!’ That happens perhaps once or twice a year, and I feel excited that someone out there is thinking originally about our field. The constant parade of fashions without genuine creativity makes me think that our field needs, like Proust, not to seek new landscapes but to have new eyes

In lieu of eye transplants, I guess the Psychiatric Multiverse will have to do.

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To make amends for my honestly random, yet still distressing selection as a town to be hypothetically destroyed by a hurricane, here are some of the many reasons to visit Stockton on Tees:
A) It was one end of the Stockton and Darlington Railway - the first steam train passenger railway
B) It has pretty bridges like the Infinity Bridge:

C) It has one of the oldest markets in England, dating back to 1310
D) There is plenty to see and do in the town

What would happen if every psychiatrist was 1% moth? How would psychiatrists commute if the earth succumbed to a devastating greenhouse effect resulting in floating cities in the sky? These are the questions that no one is asking, with wildly speculative answers. Welcome to the Psychiatric Multiverse!

Each article in this newsletter proposes a hypothetical parallel universe (a “Psyverse”) where psychiatric culture is changed by a technique, idea or perspective from another area or subject. It will be weird. It will be wacky.

I am Alex Mendelsohn, a distinctly ordinary physicist with an out of the ordinary story. Much of this newsletter will be inspired by my decade as a patient in the psychiatric system.

In a contender for the most obvious statement of the year: being sick has several drawbacks. One such drawback is a lack of energy.

Many a writer starts a newsletter with well-meant optimism. “I shall write two articles a week!” they might think, before eventually settling down into one article a month.

I intend to start with well-meant pessimism. Recovering from mental illness while rebuilding my social life and career is a time-consuming process – keeping to a regular schedule of posts will initially be… difficult. So, I’m currently building a backlog of articles, to take some time-pressure off.

I’m hoping that within the next six months I’ll have this newsletter up and running, but I’m not putting a date on it. When the time does finally arrive, I’ll aim to post once a month and everything will be free. In the meantime, please feel free to have a look at some of my previously published articles.

This newsletter is by no means intended to be a lopsided multiverse. If you have a left-field ridiculous idea about how the psychiatric system could be improved and want to have a little bit of fun, please do reach out1.

That is all for now, see you in the first Psyverse!