Citation

Ramanujam R, Goodman PS. Safety Sci. 2011; 49(1): 83-89.

Copyright

(Copyright © 2011, Elsevier Publishing)

DOI

10.1016/j.ssci.2010.03.019

PMID

unavailable

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.