“The gift of failure: New approaches to analyzing and learning from events and near-misses.” Honoring the contributions of Bernhard Wilpert

Abstract

a b s t r a c tThis special issue presents papers from a workshop conducted by New Technologies and Work (NeTWork) to honor the memory of Bernhard Wilpert, the founder and organiser of NeTWork. The papers reflect the theme that undesirable incidents and events, serious and disturbing as they may be, are a ''gift of failure." In short, events offer an opportunity to learn about safe and unsafe operations, generate productive conversations across engaged stakeholders, and bring about beneficial changes to technology, organization, and mental models (understanding). Papers in the special issue are organised around three topics: the process of event analysis, the relationship between event analysis and organisational learning, and learning at multiple system levels. In this introduction we describe the workshop, summarize the contributions of Bernhard Wilpert, suggest three themes that emerged from the workshop, and offer our thoughts about the future of event analysis and learning from events.Ó 2010 Elsevier Ltd. All rights reserved. Background to the special issueThe same wondrous technologies that underlie our modern societies, such as air and sea transportation, nuclear power, and health care, also lead to challenges to safety: their innovativeness and complexity makes them difficult to predict and control (Beck, 1992;Perrow, 1984; Rollenhagen, this issue). As well, organizations ''push the limits" for greater productivity with more complex, software-intensive systems that require interdependent participation from multiple professionals. The public demands more safety at the same time as it demands more services at less cost, while corporate shareholders demand higher returns. These issues are of great importance in so-called ''high-hazard" industries where a rare and surprising event can place hundreds or thousands of people at risk, however, they are also of importance in settings such as health care and ordinary workplaces where undesired events occur more frequently but lives are disrupted one at a time.Organizations need appropriate structures, rules, and practices to avoid and respond appropriately to safety relevant events, in order to ensure their safety and reliability. These structures and rules are the safety management system that is based on both anticipatory feed-forward models of risk and strategies for feedback control (Rasmussen, 1990). Of course, we cannot completely specify all risks: even if risks are specified within the operating envelope, in real life organizations sometimes operate beyond their operating envelope (some scholars would say, all the time). Therefore, adequate feedback control relies on learning from operational experience. Organizational weaknesses and latent failures (e.g., Reason, 1997) are identified by continual monitoring and systematic analyses of problems, deviations, defects, events, near-misses and organizational surprises. Results of event analyses should lead to new knowledge, new structures, new rules, and new practices with the goal of higher reliability and saf...

What Is Learning? A Review of the Safety Literature to Define Learning from Incidents, Accidents and Disasters

“…However, to successfully learn, it is important to go from identification of lessons learned, to the implementation of these lessons. Some follow‐up steps are necessary, such as practical recommendations and actions that lead to effective interventions (Carroll & Fahlbruch, ; Lindberg et al., ; Le Coze, ; Wahlström, ), meaning the lessons learned need to be applied. This section describes the learning processes as described in literature.…”

Analyse des risques en radiothérapie

“…Tout en s'inscrivant dans le champ des méthodes participatives d'analyse des risques développées dans le domaine médical et dans certaines industries à risques, ce travail cherche à s'en éloigner. Au lieu d'aborder les risques à partir d'analyses d'accidents (Carroll et Fahlbruch, 2011 ;Schöbel et Manzey, 2011), de situations non nominales (Nascimento, 2009), de situations dangereuses (Osario et Clot, 2010 ;Rocha, 2014), de situations critiques (Casse, 2015), nous proposons aux analystes (équipe soignante restreinte) de caractériser et d'étudier des situations complexes. Nous faisons l'hypothèse dans ce travail que la complexité du travail peut générer des situations risquées pour les patients.…”

Designing System Reforms: Using a Systems Approach to Translate Incident Analyses into Prevention Strategies

“…This lack of research into the design of prevention strategies implies that there is a belief that the analysis of incident data will automatically lead to new knowledge, new structures, new rules, and new practices that will result in higher reliability and improved safety once implemented (Lundberg et al, 2010; Carroll and Fahlbruch, 2011; Drupsteen et al, 2013b). However, examinations of investigation manuals show that little guidance is provided on how to design prevention strategies based on the outputs from an investigation (Lundberg et al, 2009; Rollenhagen et al, 2010; Drupsteen et al, 2013b).…”