The occurrence of everyday medical mishaps in this study is associated with faulty communication; but, poor communication is not simply the result of poor transmission or exchange of information. Communication failures are far more complex and relate to hierarchical differences, concerns with upward influence, conflicting roles and role ambiguity, and interpersonal power and conflict. A clearer understanding of these dynamics highlights possibilities for appropriate interventions in medical education and in health care organizations aimed at improving patient safety.

In this article, we elucidate how the Navajo synthetic principle sa'ah naagháí bik'eh hózh [symbol: see text] (SNBH) is understood, demonstrated, and elaborated in three different Navajo healing traditions. We conducted interviews with Navajo healers and their patients affiliated with Traditional Navajo religion, the Native American Church, and Pentecostal Christianity. Their narratives provide access to cultural themes of identity and healing that invoke elements of SNBH. SNBH specifies that the conditions for health and well-being are harmony within and connection to the physical/spiritual world. Specifically, each religious healing tradition encourages affective engagement, proper family relations, an understanding of one's cultural and spiritual histories, and the use of kinship terms to establish affective bonds with one's family and with the spiritual world. People's relationships within this common behavioral environment are integral to their self-orientations, to their identities as Navajos, and to the therapeutic process. The disruption and restoration of these relationships constitute an important affective dimension in Navajo distress and healing.

The past 20 years have seen a florescence in studies of religious and ritual healing. This article broadly surveys this literature on a global scale, organizing and presenting the studies by geographical region. Summaries of major themes in the regional literatures follow each section, and suggest that differences and similarities may be as much a product of theoretical orientations brought by students of healing to their work, as of empirical features observed ethnographically. A concluding section raises the issue of therapeutic efficacy, summarizing the major contributions during the two decades covered by this article.

Objectives: To evaluate resident experience and perceptions of medical error associated with emergency department (ED) care. Methods: Using a semistructured interview protocol, three researchers interviewed 26 randomly selected medical, surgical, and obstetrics residents regarding medical error. The authors chose a 16-case subset of incidents involving ED care for initial review. Interview transcripts were reviewed iteratively to draw out recurrent categories and themes. Two investigators separately analyzed all cases to ensure common understanding and agreement. Results: Most cases involved misdiagnosis, misread radiographs, or inappropriate disposition. Two thirds of the case patients died or experienced delays in care. Residents felt that the complexity of the patients, as well as the complexity of their own jobs, contributed to error. Attending supervision, nurse evaluation, and additional physician involvement all were noted to be important checks within the hospital system. Residents most often held the ED responsible for error. In addition, they deemed themselves, their teams, and their lack of training responsible. Though residents often discussed events with their admitting teams, follow-up with the ED or other associated individuals was uncommon. The findings revealed seven common themes that include factors contributing to errors, checks and adaptations, and follow-up of the event. Conclusions: Residents are aware of medical error and able to recall events in detail. Whereas events are discussed among inpatient teams, little information finds its way back to the ED, potentially resulting in misunderstandings between departments and hindering learning from events. In-depth interviewing allows a nuanced and detailed approach to error analysis.

The mental health of physicians in training is a topic of considerable concern. Recent attention to the issue of patient safety has led to examination of the relationship between residents' stress and compromised clinical performance. Few mental health programs dedicated to residents and formally structured to meet their specific needs are reported in the literature. The authors raise the question of why there are so few programs and why more residents don't take advantage of services that do exist. They then describe the development and utilization of the University of Michigan Health System's House Officer Mental Health Program. The program was structured to overcome barriers to utilization such as lack of funding, concerns about confidentiality, ease of access and residents' financial constraints and to provide comprehensive services for a wide range of diagnoses. Data are presented on the first four years of operation from 1997-01 that show increasing utilization and high levels of satisfaction over this time period by house officers at all levels of training and in all departments of the Health System. As increasing attention is paid to how to deal with medical errors, the establishment of such programs should be considered, not only as a means to address the general mental health of residents but also as an appropriate venue to deal with the stress that can contribute to and be induced by medical mishaps.