Publication Date


Document Type


Committee Members

Kevin Bennett (Committee Member), Nancy Elder (Committee Co-chair), John Flach (Advisor), Valerie Shalin (Committee Member)

Degree Name

Master of Science (MS)


Four mid-Western family practices were studied using three methods (observations, interviews, and an audit of patient records) in effort to discover the dynamics and constraints of their diagnostic testing processes. We have found further evidence that errors do occur at many of the steps in the processes, but that the patterns of those errors are not independent of each other and are a function of systemic factors unique to each practice. Furthermore, while many employees or steps in the process may be considered a source of error, they were also shown to be major sources of quality and safety in their testing respective systems. Safety was created when employees recognized the natural feedback loops that allowed them to learn to compensate and correct errors.

Page Count


Department or Program

Department of Psychology

Year Degree Awarded