Learning from Incidents
A long-form story of a technology infrastructure incident — what happened, how the team responded, and how they'd prepared the conditions for learning before anything went wrong. Shows that incident learning is only possible where the social conditions for honesty already exist.
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Neighbours (12)
- Behind Human Error: Cognitive Systems, Computers, and Hindsight
- How Complex Systems Fail: Being a Short Treatise on the Nature of Failure, How Failure is Evaluated, How Failure is Attributed to Proximate Cause, and the Resulting New Understanding of Patient Safety
- Catastrophe and Systemic Change: Learning from the Grenfell Tower Fire and Other Disasters
- From Titanic to Costa Concordia — a Century of Lessons Not Learned
- HOP
- How Effectively Has a Just Culture Been Adopted? A Qualitative Study of Clinicians' and Managers' Attitudes to Clinical Incident Management Within an NHS Hospital Trust
- Just Culture
- Learning from Error
- Individual Involvement and Intervention in Quality Improvement Programmes: Using the Andon System
- PSIRF
- F**k-ups & Feedback
- Mining for Root Causes