Elsevier

Safety Science

Volume 49, Issue 1, January 2011, Pages 83-89
Safety Science

The challenge of collective learning from event analysis

https://doi.org/10.1016/j.ssci.2010.03.019Get rights and content

Abstract

This paper examines the difficulties of learning from event analysis. The central idea is that learning represents a distinct set of team-or unit-level outcomes and processes that is different from valid analysis, effective problem-solving, or individual learning. In other words, event analysis cannot automatically generate group learning. For learning to occur, several conditions must be satisfied: Change in the team’s or unit’s repertoire of behaviors (the learning) must be a clear outcome of the event analysis; this learning must be shared by the team members (i.e., members must become aware of both the content of the learning as well as of the fact that other members are aware of this learning); the shared learning must be stored in repositories for future retrieval; the stored learning must be retrieved when the team subsequently encounters situations where the learning is relevant; and, finally, these processes of sharing, storing, and retrieving the learning must continue to occur over an extended period of time. These requirements pose major dilemmas or challenges for learning from event analysis. We discuss these challenges using examples from event analysis teams in two hospitals and in a computer emergency response center. We offer some potential strategies for addressing these challenges.

Introduction

This paper examines the linkages between event analysis and learning. Event analysis involves an investigation of a focal event, such as an accident or error, which can be costly to an organization. The objective is to identify the major causes of the event and implement corrective actions to prevent the event from recurring. Learning refers to the acquisition of new repertoires of behaviors (e.g., corrective actions from event analysis). One premise in event analysis is that learning should follow from event analysis. We argue that many features of event analysis, as typically carried out, present significant obstacles to learning. In developing this argument, our specific goals are to (1) examine some of the obstacles that prevent event analysis from contributing to learning, and (2) identify strategies that might facilitate learning from event analysis. To this end, we address the following questions: What are the basic features of event analysis that are relevant to understanding the challenges of learning from event analysis? What do we mean by learning and how are the outcomes and processes of learning distinct and different from event analysis? What are the major obstacles or dilemmas in moving from event analysis to learning? And finally, what are the strategies for creating better linkages between event analysis and learning?

We have several objectives for drawing attention to these questions. First, we wish to clarify the notion of learning in the context of event analysis by discussing not only what learning is but also what learning is not. Such delineation is critical because discussions of event analysis frequently equate “learning” with effective problem-solving and improvement in safety outcomes. However, as we discuss later in this paper, learning refers to a distinct set of outcomes and processes that can occur with or without valid event analysis. Second, we seek to highlight an underappreciated feature of event analysis: it is almost always a social activity. The fact that event analysis is typically carried out by individuals or groups presents the challenge of determining who learns from the process. Not only is group or unit learning different from the learning of the individual members of the team, but the processes that contribute to group learning also differ from the processes that contribute to learning of individual group or unit members (Wilson et al., 2007). We identify and discuss the characteristics or features of group learning that are especially important for understanding learning from event analysis. Third, we wish to identify major dilemmas or challenges that teams encounter in attempting to learn from event analysis. Discussions of event analysis often tend to ignore challenges that are inherent in the complexity of group or unit learning. Finally, we discuss some strategies for strengthening the link between event analysis and learning. Simply stated, it is necessary to understand what learning is (and is not) in order to determine whether event analysis is effective with respect to one of its most important goals (i.e., learning) and to design targeted interventions for enhancing its effectiveness.

In addressing these questions, we draw from our ongoing work on event analysis in computer emergency response teams and hospitals. In one study (Goodman and Wilson, 2003), we observed teams at a national computer emergency response center that respond to threats or attacks, such as a widespread worm or virus, on the internet infrastructure. Whenever such an attack occurs, an incident response team is formed to deal with the attack. This team works with external experts to identify a fix or patch, keeps the broader community informed about the incident, and generally serves as an unbiased source of information (i.e., not affiliated with any software providers). We directly observed several meetings that the response team would hold after each event (e.g., a virus attack) to analyze how it had responded and to learn about improving its response to future events. In another study (Ramanujam et al., 2005, Anderson et al., 2010), we examined the efforts of two hospitals to analyze the adverse events in their medication administration processes. In each hospital, multi-disciplinary teams analyzed critical medication errors, defined as instances where the patient was harmed, with a view to identifying the underlying causes and learning to prevent future occurrences. We attended multiple meetings where the teams analyzed critical medication errors. In addition, we also interviewed participants individually to collect information about corrective actions that were implemented following the event analysis. Notes from the observations and interviews were analyzed to draw inferences, which were subsequently shared with the participants for validation. We provide examples from these settings below to illustrate our arguments.

Section snippets

Variations in the practice of event analysis

To set the stage, we discuss some basic features of event analysis that can vary across settings and can potentially influence the process of learning. Broadly, event analysis can be characterized in terms of the focal event, purpose, analysis method, and participants. With respect to the focal event being analyzed, the criteria used to select an event for in-depth analysis can vary across organizations. For instance, in both the hospitals that we studied, medication errors were defined as any

Differentiating learning from event analysis

Following Wilson et al. (2007), we define learning from event analysis as a change in the repertoire of behaviors in the entity that stems from the analysis activities. In this case, learning represents a shared understanding among group members of a new course of action to minimize or prevent the recurrence of negative events. In the hospital example, let’s assume a unit had an increase in medication errors. An event analysis might lead to a new set of activities designed to reduce medication

Articulating learning processes

Given our goals—to identify the dilemmas inherent in learning from event analysis and to explore potential strategies for managing these dilemmas—we need to further clarify the outcomes and processes of learning. As an outcome, learning represents the acquisition of new repertoires, representing a change in a group’s potential behaviors (Huber, 1991). The repertoire, which is linked to the solution identified by the team following the event analysis, could be a new task strategy for

Dilemmas in learning from event analysis

One of the questions we posed at the beginning of this paper was about identifying the major obstacles or dilemmas in moving from event analysis to learning. Our descriptions of event analysis and learning point to various reasons that make it difficult for groups to learn from event analysis and utilize these new and more effective repertoires. Some of the reasons include:

Failure to distinguish between stopping at analysis and learning from analysis. As discussed earlier, learning differs from

Strategies to improve the event-analysis-learning link

The above dilemmas present major challenges to learning from event analysis. In this section, we draw from the literature on learning as well as our observations to suggest some strategies for addressing these dilemmas. We recognize, however, that there is much in this regard that remains unknown and further research is warranted.

There are several strategies that can potentially strengthen the linkage between event analysis and learning. Our discussion draws from our conceptualization of team

Conclusions

The goal of this paper was to draw attention to the conceptual and managerial challenges in learning from event analysis. The central idea is that, both in theory as well as in practice, learning represents a set of team-or unit-level outcomes and processes that are different from valid analysis, effective problem-solving, or individual learning. In other words, event analysis cannot automatically generate group learning. Teams must develop an informed and purposeful set of strategies to learn

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