The CIEHF has just released their latest White Paper on 'Learning from Adverse Events' which lays out 9 principles for organisations to follow.
There has been enormous progress in safety over the years, yet the
frequency with which major adverse events continue to occur across
nearly every sector of the economy and the extent of the pain,
suffering, loss and hardship that arises, suggests a fundamental
weakness in the ability of developed societies to adequately learn from
the things that go wrong, and to take action that's effective in
preventing recurrence of similar events.
The 56-page document is designed to:
1. Help organisations understand a human factors perspective to investigating and learning from adverse events.
2. Provide key principles organisations can apply to capture the human contribution to adverse events.
Follow this link to download the white paper.