This webinar reframes learning as meaningful change, highlighting why recommendations for improvement are often not as effective as they should be because they don't, for example, challenge assumptions or involve the right people. By promoting participatory approaches and emphasising evaluation of real impact, it potentially strengthens the credibility and effectiveness of SLRs.
Learning from Incidents - Tracey Herlihey & Melanie Ottewill
Four things you will hear about in this pre-recorded webinar:
Outline that learning is not just gaining knowledge but creating meaningful change. The session explains why true learning requires new insights, not repeating what we already know, and why investigation reports must add new understanding rather than just describing events.
Explaining that single‑loop learning simply tweaks existing processes. Double‑loop learning challenges underlying assumptions and redesigns the work itself.
Proposing that real learning happens through conversation, engagement, and sense‑making—not through broadcasting safety alerts or reports. Staff, leaders, and teams must actively participate, question, and co‑create solutions to embed change.
Highlighting why trust, psychological safety, high‑quality investigations, and organisational motivation are essential. Blame, fear, and lack of follow‑up on outcomes undermine learning and prevent meaningful improvement
