Why do organizations not learn from incidents? Bottlenecks, causes and conditions for a failure to effectively learn

Learning from incidents in health care: Critique from a Safety-II perspective

“…Despite these advances described in the literature, empirical work suggests that substantive difficulties still persist across industries, and that organisations are struggling to transform knowledge about vulnerabilities into change in practice (Drupsteen and Hasle, 2014, Anderson and Kodate, 2015, Le Coze, 2013 2015, Pilbeam et al, 2016, Vastveit et al, 2015. The studies suggest that weaknesses exist in all steps of the learning cycle affecting both the breadth and the depth of learning (Lukic et al, 2012).…”

“…While the literature on learning from incidents can be considered fragmented (Lindberg et al, 2010), there have been attempts to draw together key aspects into empirical and theoretical models. A key feature of such models, such as those proposed by Lindberg and colleagues (Lindberg et al, 2010), Jacobson and colleagues , and Drupsteen and colleagues Guldenmund, 2014, Drupsteen andHasle, 2014) is the consideration of learning from incidents as a process. Typically, a learning process includes not only the investigation of incident data, but also the steps that occur before (data acquisition) and after (such as deciding on interventions, implementation, and evaluation).…”

“…An alternative process proposed by Drupsteen and colleagues Guldenmund, 2014, Drupsteen andHasle, 2014) attempts to integrate the Deming cycle of business improvement (Deming, 1982) with the organisational learning theory developed by Argyris and Schön (Argyris and Schön, 1996) in order to enable organisations to improve their ability to diagnose difficulties arising from their process of learning from incidents. Their descriptive-explanatory model was developed through a combination of expert opinion, an overview understanding of existing systems used by large petrochemical and petroleum companies, and a literature review on learning from safety incidents and accidents (which notably excluded health care) (Drupsteen et al, 2013).…”

“…Learning from past experiences does not have to be limited to the consideration of incidents, but can also include monitoring and analysis of leading indicators, or even weak signals (Drupsteen and Wybo, 2015). However, increasing evidence in the literature indicates that effective learning from past experiences in order to improve safety performance has proven to be difficult (Le Coze, 2013, Lukic et al, 2012, Drupsteen and Hasle, 2014.…”

Implementing Healthcare Improvement

“…Learning from past experiences does not have to be limited to the consideration of incidents, but can also include monitoring and analysis of leading indicators, or even weak signals [62]. However, there is increasing evidence in the literature that suggests that effective learning from past experiences in order to improve safety performance remains challenging even in traditional safety-critical industries [59,61,63].…”