ABSTRACT
In every human endeavor, successful outcomes begin with a good plan and design. Good design requires innovative thinking and the ability to learn from successful outcomes. Unfortunately, more often than not, we wait to learn from mistakes and failures, particularly in high-risk and complex organizations. However, learning in most organizations is limited by internal and external, perceived and real communication barriers. Hence, these organizations are continually challenged with the need to vastly improve operations, safety, and outcomes. In today’s world of 24-hour news coverage and instant messaging, operational risks (e.g., collapse of construction cranes, collisions on the runway, accidental release of toxic chemicals, product recalls, nosocomial infections, overdoses of heparin, and wrong-site surgery) that result in injury and fatality are magnified many fold in news media.
