This next topic addresses a concept called first order and second order problem solving. This concept is a very important one and was described very well by Anita Tucker and colleague. And in the reference that's on your screen, I encourage you to pull that reference and take a close look at it. It's Why Hospitals Don't Learn From Failures is the title, and I think you'll find it very interesting. So, here's the idea. Let's consider the following problem. A nurse doesn't have the medication when needed for administration. Using first order problem solving, and that's similar to reductionistic thinking. What we do is say, "Okay, I don't have the medicine that I need right now, so I'm just going to borrow the medicine from another patient." Now, that solution solves the problem at hand without decreasing the chance of error recurrence. It's pro is that it's very fast. It's con is it does not address why the error occurred and doesn't create a fix that's really gonna prevent recurrence. In second order problem solving, we're using holistic thinking. What we should do is to consider upstream process steps to identify root causes of the error that we're having. So, let's look at this example again. The nurse doesn't have the medicine at the time they need it. So, what we may do is identify and resolve the many upstream processes that lead to missing doses. The pro is that it may decrease error recurrence. The con is that it's very time consuming. As an aside, one of the things you might try is this. If you have a staff, what you might do is ask them to carry around a card, and when they encounter a problem like a missing dose, write it down. And while they may not be able to apply second order problem solving right there on the spot because they're taking care of patients, they might just have to solve the problem as best they can on the fly, but then, when you have a staff meeting, everybody can pull out their cards, look to see what those problems are and as a team, try to address the issues that come up in a second order holistic way of thinking.