Proceedings of the 12th European Conference on Knowledge ...

Tony K. M. Lo and Patrick S.W. Fong
learners to obtain substantive knowledge on why <strong>the</strong> incident happened. The specific context may be
a clue for double-loop learning and help learners connect to what <strong>the</strong>y have experienced.
Figure 2: A lesson learned - a case <strong>of</strong> medication error “wrong drug administered” (MIRP bulletin
issue no. 25, 2010, HKHA)
On <strong>the</strong> o<strong>the</strong>r hand, <strong>the</strong> bulletin is weak in conveying experience. Most <strong>of</strong> <strong>the</strong> mistakes mentioned in
<strong>the</strong> bulletin are due to cognitive errors. Yet <strong>the</strong>re is a lack <strong>of</strong> explanation <strong>of</strong> <strong>the</strong> staff’s feelings, which
could have been useful in enabling learners to imagine what <strong>the</strong>y could have done if <strong>the</strong>y had been
<strong>the</strong> participants. Recommendations provided in <strong>the</strong> bulletin are <strong>of</strong>fered top-down. They are <strong>the</strong> major
messages that <strong>the</strong> author wants to convey. However, opportunities for reflective thinking by attacking
underlying assumptions are hard to find in <strong>the</strong> content <strong>of</strong> <strong>the</strong> bulletins. In <strong>the</strong> MIRP, <strong>the</strong> assurance <strong>of</strong>
independent, objective and trustful investigation results is <strong>of</strong> top priority; greater effort is <strong>the</strong>refore
necessary to transfer <strong>the</strong> knowledge and experience from <strong>the</strong> participants to <strong>the</strong> learners.
This paper does not claim to prove that lessons learned with rich context and experience must be
better than those without or with just a little. We propose an alternate approach to assessing <strong>the</strong>
quality <strong>of</strong> lessons learned besides <strong>the</strong> quantitative approach. In <strong>the</strong> future, <strong>the</strong> questions checklist can
be enriched and improved by interviewing with stakeholders or taking into consideration experts’
views which can make <strong>the</strong> questions more objective. Rubrics for assessment can be designed on <strong>the</strong>
basis <strong>of</strong> opinions obtained from stakeholders and experts, as well as from an analysis <strong>of</strong> literature and
o<strong>the</strong>r research results. More cases in safety can be studied as comparison, especially for those in
o<strong>the</strong>r industries like construction and security.
Acknowledgement
The work described in this paper was fully supported by a grant from <strong>the</strong> Research Grants Council <strong>of</strong>
<strong>the</strong> Hong Kong Special Administrative Region, China (Project no.: PolyU 5160/07E).
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