Learning from Adverse Events

This white paper represents the combined efforts of a number of CIEHF members. It shares their considerable knowledge and experience of human factors in incident prevention and management, and is designed to: 1. Help organisations understand a human factors perspective to investigating and learning from adverse events. 2. Provide key principles organisations can apply to capture the human contribution to adverse events. pdf youtube bit.ly link (keeping the bit.ly link too in case the direct link changes in the future and the org maintains the short link).

Nine principles for incorporating human factors into learning investigations are identified. They are embedded throughout the document, collated in section 5 and summarised below:

1. Be prepared to accept a broad range of types and standards of evidence.

2. Seek opportunities for learning beyond actual loss events.

3. Avoid searching for blame.

4. Adopt a systems approach.

5. Identify and understand both the situational and contextual factors associated with the event.

6. Recognise the potential for difference between the way work is imagined and the way work is actually done.

7. Accept that learning means changing.

8. Understand that learning will only be enduring if change is embedded in a culture of learning and continuous improvement.

9. Do not confuse recommendations with solutions.

Suggestion for applying the guidance. Organizations can conduct an internal gap analysis about how their own practices line-up with the nine principles. In particular, what evidence can be shown to back up the gap analysis?

What we're looking for is the change.

If we are to be a high-performing organization, these guidelines are the sort of things we must be following.

"Learning pathways" — one of several adoption strategies under consideration by UK's NHS to adopt for better dissemination of the guiding principles. This notion is credited to a practice from oil & gas industry.

I'm interested in this phrase because I know more than one part of the federated wiki which is interested in learning pathways.