New Zealand health care system adopts ‘Learning Review’ process developed by UAB School of Engineering faculty

Ivan Pupulidy, Ph.D., and Crista VeselTwo faculty members in the University of Alabama at Birmingham School of Engineering Advanced Safety Engineering and Management Program have developed and implemented an accident investigation tool that was recently adopted by the New Zealand Health Quality and Safety Commission.

Longtime safety professionals, Ivan Pupulidy, Ph.D., and Crista Vesel understand all too well the high stakes involved in human endeavors.

Pupulidy says, when an accident results in catastrophic consequences, well-intentioned investigations could have unintended results.

“If investigators are searching for a person to blame, they will usually find a scapegoat,” Pupulidy said. “However, that does very little to prevent similar accidents from happening again.”

Pupulidy, former director of the Office of Innovation and Organizational Learning for the United States Forest Service, developed and implemented the Learning Review in 2013. The process sought to shift the focus from laying blame on human error to instead understanding why it made sense for people to do what they did.

“The Learning Review was originally designed for the Forest Service to replace the ‘Serious Accident Investigation Guide,’” Pupulidy said. “It was designed to understand the context that surrounds human decisions and actions.”

“When a serious accident occurs, you get the money, the time and the people to investigate the accident; but there is an urgency to the investigation that can often prevent learning from the accident,” Vesel said. “Investigators already have an idea in mind of where they want to go with the investigation to get to ‘the cause’ of the accident.”

Pupulidy says in the development of the Learning Review he analyzed how traditional investigations tend to judge the actions as being bad if there is a negative result but when the innovation (action) is successful it is rewarded as thinking outside of the box.

“When we approached an investigation from this perspective, we started asking much better questions,” Pupulidy said. “The result was a very context-rich narrative and suite of findings that we brought to leadership, and leadership said, ‘We need more of this.’”

Since its initial implementation in 2013, Pupulidy says some of the gains have been profound.

“We had 400 firefighter line-of-duty deaths between 1992 and 2007 — an average of around 20 fatalities per year, which remained steady for years,” Pupulidy said. “That number has dropped off to less than five per year. In fact, it’s dropped off enough to where we don’t even look at the statistics the same way anymore.”

Since Pupulidy’s retirement from the Forest Service, he and Vesel have helped implement the Learning Review in various industries around the world, including aviation, light rail in Europe and Great Britain, and most recently in the New Zealand health care system.

“We were very proud to hear that the entire medical system in New Zealand has adopted the Learning Review,” Pupulidy said.

Vesel discussed how the Learning Review is incorporated into the UAB curriculum.

“In the ASEM program, we teach a course on the Learning Review called ‘Learning-based Response to Accidents and Incidents,’ as well as a course in the language of safety, crisis leadership, and a course in critical thinking that is preparation for the capstone where we bring in elements of social psychology,” Vesel said.

Pupulidy mentioned he and Vesel plan to further utilize the principles of the Learning Review to help develop the future of safety systems here at UAB.

“In spring 2024, we will start two new courses: Applied Semiotics in Safety, and Human and Organization Potential,” Pupulidy said. “Many of the concepts that are at play in the Learning Review are relevant to all of these courses and play an important role in preparing our students to improve safety programs around the world.”