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.

The study of errors in the health system today is a topic of considerable interest aimed at reducing errors through analysis of the phenomenon and the conclusions reached. Errors that occur frequently among health professionals have also been observed among nursing students. True, in most cases they are actually “near errors,” but these could be a future indicator of therapeutic reality and the effect of nurses' work environment on their personal performance. There are two different approaches to such errors: (a) The EPP (error prone person) approach lays full responsibility at the door of the individual involved in the error, whether a student, nurse, doctor, or pharmacist. According to this approach, handling consists purely in identifying and penalizing the guilty party. (b) The EPE (error prone environment) approach emphasizes the environment as a primary contributory factor to errors. The environment as an abstract concept includes components and processes of interpersonal communications, work relations, human engineering, workload, pressures, technical apparatus, and new technologies. The objective of the present study was to examine the role played by factors in and components of personal performance as compared to elements and features of the environment. The study was based on both of the aforementioned approaches, which, when combined, enable a comprehensive understanding of the phenomenon of errors among the student population as well as a comparison of factors contributing to human error and to error deriving from the environment. The theoretical basis of the study was a model that combined both approaches: one focusing on the individual and his or her personal performance and the other focusing on the work environment. The findings emphasize the work environment of health professionals as an EPE. However, errors could have been avoided by means of strict adherence to practical procedures. The authors examined error events in the administration of medication by nursing students during 1999–2006 using narrative analysis and the qualitative triangulation method. The findings result in a recommendation to reconsider the mode of approaching errors in educational processes, the handling of errors in the clinical field, and improvement of the safety climate.