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Many incidents have occurred because organisations have failed to learn from lessons of the past. This means that there is room for improvement in the way organisations analyse incidents, generate measures to remedy identified weaknesses and prevent reoccurrence: the learning from incidents process. To improve that process, it is necessary to gain insight into the steps of this process and to identify factors that hinder learning (bottlenecks). This paper presents a model that enables organisations to analyse the steps in a learning from incidents process and to identify the bottlenecks. The study describes how this model is used in a survey and in 3 exploratory case studies in The Netherlands. The results show that there is limited use of learning potential, especially in the evaluation stage. To improve learning, an approach that considers all steps is necessary.
Wydawca
Rocznik
Tom
Strony
63--77
Opis fizyczny
Bibliogr. 39 poz., rys., tab., wykr.
Twórcy
autor
- TNO Work and Employment, The Netherlands
autor
- Leiden University, Leiden, The Netherlands
- TNO Work and Employment, The Netherlands
autor
- TNO Work and Employment, The Netherlands
- Institute of Work, Health and Organisations, Nottingham University, Nottingham, UK
Bibliografia
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- 4.Kletz T. Learning from accidents. 3rd ed. Oxford, UK: Butterworth-Heinemann; 2001.
- 5.van der Schaaf TW. Near miss reporting in the chemical process industry [doctoral dissertation]. Eindhoven, The Netherlands: Eindhoven University of Technology; 1992. Retrieved December 14, 2012, from: http://alexandria.tue.nl/extra3/proefschrift/PRF8B/9205360.pdf.
- 6.van Vuuren W. Organisational failure: an exploratory study in the steel industry and the medical domain [doctoral dissertation]. Eindhoven, The Netherlands: Eindhoven University of Technology; 1998. Retrieved December 14, 2012, from: http://alexandria.tue.nl/extra3/proefschrift/boeken/9800441.pdf.
- 7.Reason J. Managing the risks of organizational accidents. Aldershot, UK: Ashgate; 1997.
- 8.Carpenter JK, Hendershot DC, Watts SJ. Learning from reactive chemistry incidents. Chem Health Saf. 2004;11(4):10–6.
- 9.Carroll JS. Organisational learning activities in high-hazard industries: the logics underlying self-analysis. Journal of Management Studies. 1998;35(6):797–822.
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- 29.Firth-Cozens J. Organisational trust: the keystone to patient safety. Qual Saf Health Care. 2004;13(1):56–61. Retrieved December 14, 2012, from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1758064/pdf/v013p00056.pdf.
- 30.Hopkins A. A corporate dilemma: to be a learning organisation or to minimize liability. Journal of Occupational Health and Safety: Australia and New Zealand. 2006;22(3):251–9.
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- 32.Barret JH, Haslam RA, Lee KG, Ellis MJ. Assessing attitudes and beliefs using the stage of change paradigm – case study of health and safety appraisal within a manufacturing company. Int J Ind Ergon. 2005;35(10):871–87.
- 33.Bahn S. Power and influence: examining the communication pathways that impact on safety in the workplace. Journal of Occupational Health and Safety: Australia and New Zealand. 2009;25(3):213–22.
- 34.Argyris C, Schon DA. Organizational learning: a theory of action perspective. Reading, MA, USA: Addison-Wesley; 1978.
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Typ dokumentu
Bibliografia
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