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PSNet: Patient Safety Network
Book/Report

Organizational Learning from Experience in High-Hazard Industries: Problem Investigations as Off-line Reflective Practice.

Carroll JS; Rudolph JW; Hatakenaka S

As organizations struggle to cope with rapidly changing environments and more complex and interdependent sets of knowledge, their capacity to learn from experience grows in importance. This paper confronts two central issues for organizational learning from the prism of the chemical and nuclear industries. Lessons discussed here can be applied to health care as it seeks to learn from accident investigation.