title: TRACEing the roots: a diagnostic "Tool for Retrospective Analysis of Critical Events".
abstract: OBJECTIVE
  The lack of interdisciplinary clarity in the conceptualization of medical errors discourages effective incident analysis, particularly in the event of harmless outcomes. This manuscript integrates communication competence theory, the criterion of reasonability, and a typology of human error into a theoretically grounded Tool for Retrospective Analysis of Critical Events (TRACE) to overcome this limitation.
  
  
  METHODS
  A conceptual matrix synthesizing foundational elements pertinent to critical incident analysis from the medical, legal, bioethical and communication literature was developed. Vetting of the TRACE through focus groups and interviews was conducted to assure utility.
  
  
  RESULTS
  The interviews revealed that TRACE may be useful in clinical settings, contributing uniquely to the current literature by framing critical incidents in regard to theory and the primary clinical contexts within which errors may occur.
  
  
  CONCLUSIONS
  TRACE facilitates a comprehensive, theoretically grounded analysis of clinical performance, and identifies the intrapersonal and interpersonal factors that contribute to critical events.
  
  
  CONCLUSIONS
  The TRACE may be used as (1) the means for a comprehensive, detailed analysis of human performance across five clinical practice contexts, (2) an objective "fact-check" after a critical event, (3) a heuristic tool to prevent critical incidents, and (4) a data-keeping system for quality improvement.
authors.affiliation: Faculty of Communication Sciences, University of Lugano, Lugano, Switzerland. Electronic address: annegret.hannawa@usi.ch.
authors.forename: Annegret F
authors.initials: AF
authors.lastname: Hannawa
authors.forename: Debra L
authors.initials: DL
authors.lastname: Roter
mesh_terms: D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D012107:Research Design; D012308:Risk Management; D013647:Task Performance and Analysis
keywords: Critical incidents; Human factors; Incident analysis; Medical errors; Patient safety; Quality improvement