Preventing black swans: incident reporting systems as collective knowledge management

Abstract

In hazardous industries, disasters are mercifully rare and yet the potential is ever present. For this reason, companies and industries as a whole put substantial effort into gathering information about past small failures and their causes in an attempt to learn how to prevent more serious events. Despite these efforts, recent research has captured how organizations can 'fail' to learn. Disastrous events can become 'black swans' and remain unpredicted despite the existence of information warning of them. This article engages with this challenge by analyzing incident-reporting systems as a tool for collective knowledge. Drawing together the literatures on organizational knowledge management and incident reporting, we examine incident-reporting systems as used and as structured. We explore the potential use of incident-reporting systems for mediation and synchronization of knowledge within and across groups of professionals and organizations. We also address the social practices that translate information in databases into collective knowledge. Building on the work of Hecker, we argue that research concerned with incident reporting and organizational learning would benefit from using 'knowledge' and specifically 'collective knowledge' as its reference point. We show that conceptualizing this problem in terms of 'reporting' and 'learning' distracts attention from the knowledge needs for people to learn. We argue that we must ask: What do people need to know to play their part in major accident prevention? And how is that knowledge effectively shared? We conclude with an empirical research agenda in light of this investigation.

Impact of a Brief Educational Intervention on Knowledge, Perceived Knowledge, Perceived Safety, and Resilience of the Public During COVID-19 Crisis

“…The study identified several positive associations between examined variables, but particularly unexpected was the relationship between perceived knowledge and personal resilience, as this indicates that the perception of knowledge is more implicated in resilience, rather than actual knowledge. This observation supports the findings of Kupika et al (2019), in which higher individual perceptions of knowledge in the context of climate change were shown to promote resilience [ 23 ].Previous studies presented that perceived risk (as suggested by Paton, Mclure and Burgelt, (2006) and Lopes (2000)) predict greater community resilience [ 16 , 17 ]. The positive associations observed in the current study between perceived safety and perceived knowledge and personal resilience may suggest that beyond risk perception, perceived safety may be a predictor of personal resilience, though this has to be more extensively studied to confirm or predict this hypothesis.…”

“…In the context of disaster preparedness, knowledge may be defined as “the practice of intervening purposefully” to elucidate appropriate function, while perceived knowledge is the belief of oneself concerning the ability to implement such a function [ 17 ]. Findings indicate that the public’s knowledge is thought to have significant influence on its uptake of and adherence to control measures; conversely, knowledge gaps among the population can contribute to the reduced efficacy of control measures implemented [ 18 , 19 ].…”

Deployment of Critical Incident Reporting System (CIRS) in public Styrian hospitals: a five year perspective

“…Organizational learning by using CIRS and thereby collective knowledge are prerequisites for succeeding in patient safety. Therefore CIRS should be promoted in every healthcare organization [27].…”

The Mediating Role of Disaster Policy Implementation in Disaster Risk Reduction and Sustainable Development in Sierra Leone

“…There is an increasing consciousness among users, organizers, and experts that risk reporting should be improved, as "better risk reporting is fundamental to healthier governance" [49]. However, how best to balance what the community participants want to see in a risk report with what the organizations are willing to divulge remains unanswered [49]. In particular, organizations are unwilling to reveal anything that might impend a competitive advantage or discuss possible risks in detail if these alarms community participants.…”

“…Effective frameworks use applicable instruments to interconnect and transfer knowledge related to risk to numerous community leaders engaged in disaster decisionmaking [48]. There is an increasing consciousness among users, organizers, and experts that risk reporting should be improved, as "better risk reporting is fundamental to healthier governance" [49]. However, how best to balance what the community participants want to see in a risk report with what the organizations are willing to divulge remains unanswered [49].…”