Learning from adverse events

What are adverse events?

Adverse events are defined as either:

  • Events where there is actual harm or loss.
  • Near misses, where little harm or loss occurred, but where it is recognised that something went seriously wrong.

But it’s not enough to learn from adverse events – we must also consider learning from what have become known as ‘weak signals’. These are simply indications that something is not quite right. Sometimes, being sensitive to these weak signals and acting upon them is referred to as having ‘chronic unease’. This is a characteristic of High Reliability Organisations (HRO). I’ve written about HROs elsewhere, but in summary, it’s useful to think of them as being able to anticipate the unexpected AND contain the unexpected when it occurs.

How do you incorporate human factors into investigations?

There are nine key principles that organisations can apply to capture the human contribution to adverse events. These principles will help you to apply human factors in the investigation process. They also demonstrate how organisations learn (and fail to learn) from adverse events.

The UK Chartered Institute of Ergonomics and Human Factors (CIEHF) have published a white paper to help organisations to understand the human factors perspective to investigating and learning from adverse events, based around these nine key principles.

I have reproduced the nine principles here, but highly recommend that you review the original document for practical guidance on how to include human factors in your investigations. The white paper contains a wealth of useful information.

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

Organisations that are genuinely seeking to learn from incidents are prepared to accept the need for action and change based on informed judgements, rather than necessarily hard ‘evidence’, about why people at the sharp as well as the blunt end of the organisation may have behaved and acted in the ways they did.

Principle 2: Seek opportunities for learning beyond actual loss events.

Near misses, close calls, anonymised reporting systems and sensitivity to weak signals from operations all provide opportunity for learning and continuous improvement.

Principle 3: Avoid searching for blame.

Focusing on individual failure and blame creates a culture of concealment and reduces the likelihood that the underlying causes of events will be identified.

Principle 4: Adopt a systems approach.

Serious adverse events can only be understood in terms of the overall socio-technical system in which the event occurred. That means understanding and being open to the possibility of a need for change in any of the components of the system. Investigating why the controls the organisation thought it had in place were not effective in preventing the event, can bring a lot of insight and learning about systemic issues.

Principle 5: Identify and understand both the situational and the contextual factors associated with the Event.

Look beyond individual performance and actions, and explore the complex interplay between psychological, social and organisational factors that influence decisions and actions. Consider how interactions between situational and contextual factors could lead to unexpected or undesirable human performance.

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

Investigators must be sensitive to the fact that ‘work-as-done’ often diverges significantly from how work is documented in formal procedures, disclosed or prescribed. The goal of learning is to improve work-as-done and then seek to better align how this is more accurately described and represented in formal procedures.

Principle 7: Accept that learning means changing.

Lessons identified in an investigation report are not the same as lessons learned. If nothing changes in terms of the way the people in the organisation think, behave or react to future events and situations, nothing has been learned. Though change, in itself, does not mean effective learning – change must be effective in implementing the intent of recommendations, must be understood and accepted by those affected by it, and must be embedded so it is sustained.

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

This means a culture that is open and fair, where people value and are motivated to learn and make change for the better and where the entire organisation is engaged in the learning process; learning and change are considered normal. If an organisation is defensive, learning will be inhibited.

Principle 9: Do not confuse recommendations with solutions.

Recommendations should set out what improvement is needed, without defining how that improvement is to be achieved. Solutions are concerned with satisfying recommendations in a way that is practical, effective and sustainable. Good recommendations allow opportunity for a range of solutions. Recommendations should be linked to system performance such that the reason for the change remains understood as the solution is developed and implemented.

These nine principles can be downloaded as a PDF here.

Further reading

I highly recommend reading the white paper from the UK Chartered Institute of Ergonomics and Human Factors (CIEHF) for practical guidance on how to include human factors in your investigations.

Learning from Adverse Events, CIEHF, 23 Jun 2020. Acknowledgements: Steering Group: Ron McLeod (Chair), Jon Berman, Claire Dickinson, Donna Forsyth, Tina Worthy. https://ergonomics.org.uk/resource/learning-from-adverse-events.html

For more information on approaches to human performance in investigations, see my article on Human error, human performance and investigations (Oct, 2016).

For questions that can be used in an investigation to understand why people did what they did, see my article on 12 questions to ask in an investigation (June, 2017).

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