New tools for learning: A case of organizational problem analysis derived from debriefing records in a medical center

Vered Holzmann*, Shoshana Mischari, Shoshana Goldberg, Amitai Ziv

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Purpose - This article aims to present a unique systematic and validated method for creating a linkage between past experiences and management of future occurrences in an organization. Design/methodology/approach - The study is based on actual data accumulated in a series of projects performed in a major medical center. Qualitative and quantitative content analyses were performed on 158 debriefing documents that were generated during two years. The analyses yielded a dataset which was utilized for cluster analysis to construct an organizational hierarchical risk tree. Findings - Three major project phases were found to be the most influential: planning, executing, and controlling. The major risk areas identified were found to be those related to the initial work plan, professional responsibility definition, quality control, and communication management. Research limitations/implications - The study focuses on the aspects of organizational learning and suggests a new interpretation method for debriefing documents and a utilization method to mitigate potential risks. The most important outcome of the synergy was a new ability enabling staff members to improve their qualifications on a continuous basis. However, further research is required to examine the medical center debriefing and risk management from a long-term perspective. Originality/value - The current study was conceived during a discussion on the subject of safety improvement, where the impact of human behavior on risk events occurrence was debated. Hence, the paper was dedicated to analyzing the effects of the expanding limits of the prognosis "to err is human". The method enables organizations to develop a tailored risk mitigation plan based on its accumulated processes and projects lessons-learned. Although the paper describes a process conducted in a medical center, the method and findings are applicable to many other organizations.

Original languageEnglish
Pages (from-to)148-162
Number of pages15
JournalLearning Organization
Issue number2
StatePublished - Mar 2012
Externally publishedYes


  • Case studies
  • Communication
  • Health services
  • Human resource management
  • Knowledge creation
  • Public sector organizations


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