2020 Sessions

Organizational Learning from Adverse Events – How Highly Reliable Organizations (HROs) analyze and learn from unexpected outcomes in the workplace



Saturday, October 3, 2020


CET 7:00-7:30pm
EST 1:00-1:30pm
PT 10:00-10:30am


Nuclear power, commercial aviation, specialized military units, and other HROs do the right thing, consistently, over time, even in hazardous environments. One of the four elements that contributes to high reliability is in-depth analysis of adverse events. “Adverse events” are injuries/deaths, damage to equipment, or loss of production or data. In the traditional approach of “whoever touched it last gets fired”, organizations learn nothing and the event will eventually occur again. Organizations that do an in-depth analysis of adverse events and near misses learn how to improve their safety and operational efficiency and are much less likely to suffer a recurrence. HROs use a proven event analysis methodology to learn about the error precursors, flawed defenses, and latent system weakness that contributed to the event. It also uses a “just culture” approach to deviations from expected behaviors, realizing that the organizational factors present at the time of the event contributed as much, or even more, than the actions of individuals involved. Practical Exercise: After learning about a complex adverse event, participant breakout groups each discuss and report on assigned elements. Then all participants will discuss a just culture approach to culpability. Participants then discuss potential applications in their practice.


James E. Morrison, CPT

James E. Morrison, CPT

Training Manager, Performance Improvement, Grifols Shared Services NA, USA

Jim is a retired US Coast Guard officer who specializes in initiating a culture of safety and reliability in high-hazard operations. In his 31 years USCG, he served in Command Afloat, Operations Afloat, Operational Test Director, and Intelligence duties.

Recognized as a Certified Performance Technologist (CPT) by ISPI since 2003, Jim has led numerous event analysis teams responsible for identifying error precursors, flawed defenses, and latent system weaknesses in industrial accidents. He has implemented and sustained safety and reliability efforts for Luminant Power (Texas), Swedish Medical Centers (Seattle), Queen’s Medical Center (Honolulu), Catholic Health Initiatives (Dakotas and Minnesota), and the Duke Energy Nuclear fleet (Carolinas).

Jim currently works in performance improvement for Grifols (https://www.grifols.com/), a Spanish multinational pharmaceutical manufacturer. Grifols is the European leader and largest worldwide producer of blood plasma-based medicines to treat rare diseases.