• David L Cooke, Peter B Dunscombe, and Robert C Lee.
• Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada. dlcooke@ucalgary.ca
• Qual Saf Health Care. 2007 Oct 1; 16 (5): 342-8.

ObjectivesTo motivate improvements in an organisational system by measuring staff perceptions of the organisation's ability to learn from incidents and by analysing their personal experience of incidents.MethodsRespondents were questioned on the components of the incident learning system from both a personal and an organisational perspective. The respondents (n = 125) were radiotherapists, nurses, dosimetrists, doctors, and other staff at a major academic cancer centre. Responses were analysed in terms of per cent positive responses and response rate, differences between "frontline" and "support" staff, and the respondent's experience with incidents.ResultsRespondents were more familiar with and more positive about incident identification and reporting--the first two stages of incident learning. Their overall perception of incident learning was most influenced by the investigation and learning components of the system. Respondents in frontline positions were more positive than those in support positions about responding to, identifying and reporting incidents. Respondents reported having experienced a mean of three incidents per year, of which two were reported and two out of three of the reported incidents were investigated, and a median of two incidents being experienced and reported, but none investigated. Most incidents experienced were not captured by the organisation's existing incident reporting system.ConclusionThe survey tool was effective in measuring the ability of the organisation to learn from incidents. Implications of the survey results for improving organisational learning are discussed.

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