Memahami Proses Learning from Incident di Organisasi : Sistematik Literatur Review
Keywords:
Pembelajaran organisasi, Pembelajaran dari insiden, Transfer pengetahuan
Abstract
Pembelajaran dari insiden penting untuk peningkatan keselamatan, namun banyak organisasi kesulitan menerjemahkan data insiden menjadi hasil pembelajaran berkelanjutan. Meskipun telah banyak dilakukan penelitian tentang investigasi dan pencegahan insiden, masih terdapat kesenjangan dalam memahami bagaimana organisasi mengintegrasikan ilmu keselamatan dengan perspektif pembelajaran organisasi. Kami melakukan tinjauan sistematis terhadap 59 studi yang ditinjau dari database Scopus, Web of Science, dan ScienceDirect hingga Desember 2024 untuk mengkaji mekanisme pembelajaran dari insiden. Analisis menunjukkan bahwa pembelajaran efektif memerlukan integrasi sistem manajemen kejadian ter-standardisasi dengan intervensi budaya keselamatan, menyeimbangkan proses pembelajaran formal dan informal, serta keterlibatan kepemimpinan yang kuat. Hambatan utama meliputi pelaporan insiden yang kurang, kualitas investigasi tidak memadai, dan kehilangan koneksi selama implementasi. Tinjauan ini meningkatkan pemahaman tentang pembelajaran organisasi dari insiden dan menyoroti celah penting dalam penelitian, khususnya integrasi ilmu keselamatan dengan teori pembelajaran organisasi. Penelitian mendatang sebaiknya fokus pada pengembangan kerangka kerja yang menjembatani perspektif ini dan mengevaluasi efektivitas pembelajaran jangka panjang.
References
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Chan, C.C.A. 2003. Examining the relationships between individual, team and organizational learning in an Australian hospitalLearn. Health Soc. Care 2:4, 223–235.
Chuang, Y.-T., Ginsburg, L., dan Berta, W.B. 2007. Learning from preventable adverse events in health care organizations: Development of a multilevel model of learning and propositionsHealth Care Manage. Rev. 32:4, 330–340.
Clare, J., dan Kourousis, K.I. 2021. Learning from Incidents in Aircraft Maintenance and Continuing Airworthiness Management: A Systematic ReviewJ. Adv. Transp. 2021, 1–13.
Cong, W., Xue, H., Liang, H., Su, Y., dan Zhang, S. 2022. Informal Safety Communication of Construction Workers: Conceptualization and Scale Development and ValidationFront. Psychol. 13, 825975.
Cooke, D.L., Dunscombe, P.B., dan Lee, R.C. 2007. Using a survey of incident reporting and learning practices to improve organisational learning at a cancer care centreQual. Saf. Health CARE 16:5, 342–348.
Cooke, D.L., dan Rohleder, T.R. 2006. Learning from incidents: from normal accidents to high reliabilitySyst. Dyn. Rev. 22:3, 213–239.
Dawson, R., Saulnier, T., Campbell, A., dan Godambe, S.A. 2022. Leveraging a Safety Event Management System to Improve Organizational Learning and Safety CultureHosp. Pediatr. 12:4.
de Kam, D., Grit, K., dan Bal, R. 2019. Shared learning from incidents: A qualitative study into the perceived value of an external chair on incident investigation committeesSaf. Sci. 120, 57–66.
De Kam, D., Grit, K., dan Bal, R. 2019. Shared learning from incidents: A qualitative study into the perceived value of an external chair on incident investigation committeesSaf. Sci. 120, 57–66.
De Wit, M., dan Peuscher, W. 2008. How well do companies embed learning from industrial incidents. Dipresentasikan pada Society of Petroleum Engineers - 9th International Conference on Health, Safety and Environment in Oil and Gas Exploration and Production 2008 - “In Search of Sustainable Excellence,” hlm. 256–263.
Doytchev, D., dan Hibberd, R.E. 2007. Organisational learning in industrial companies: Experiences from Germany. Dipresentasikan pada Proceedings of the European Safety and Reliability Conference 2007, ESREL 2007 - Risk, Reliability and Societal Safety, hlm. 1309–1317.
Drupsteen, L., Groeneweg, J., dan Zwetsloot, G.I.J.M. 2013. Critical Steps in Learning From Incidents: Using Learning Potential in the Process From Reporting an Incident to Accident PreventionInt. J. Occup. Saf. Ergon. 19:1, 63–77.
Drupsteen, L., dan Guldenmund, F.W. 2014. What Is Learning? A Review of the Safety Literature to Define Learning from Incidents, Accidents and DisastersJ. Contingencies Crisis Manag. 22:2, 81–96.
Edwin, K.W., Nilsen, M., dan Albrechtsen, E. 2021. Why Is the Construction Industry Killing More Workers Than the Offshore Petroleum Industry in Occupational Accidents?Sustainability 13:14, 7592.
Gardener, N.J.L. 2003. Safety improvement through learning from incidents. Dipresentasikan pada Institution of Chemical Engineers Symposium Series, hlm. 205–216.
Gray, D. 2010. Learning from Adverse Incidents: Using Action Research Cycles to Generate Individual and Organisational Knowledge.
Haunschild, P.R., Polidoro, F., Jr., dan Chandler, D. 2015. Organizational Oscillation Between Learning and Forgetting: The Dual Role of Serious ErrorsOrgan. Sci. 26:6, 1682–1701.
Hovden, J., Storseth, F., dan Tinmannsvik, R.K. 2011. Multilevel learning from accidents - Case studies in transportSaf. Sci. 49:1, 98–105.
Huber, S., van Wijgerden, I., de Witt, A., dan Dekker, S.W.A. 2009. Learning From Organizational Incidents: Resilience Engineering for High-Risk Process EnvironmentsPROCESS Saf. Prog. 28:1, 90–95.
Igić, D., Vuković, M., Urošević, S., Mladenović-Ranisavljević, I., dan Voza, D. 2021. The relationship between ethical leadership, organizational commitment and Zero Accident Vision implementation in the defense industryInt. J. Occup. Saf. Ergon. 27:4, 1076–1086.
Jacobsen, H.K., Ballangrud, R., dan Birkeli, G.H. 2024. Learning from patient safety incidents: The Green Cross methodNurs. Crit. Care n/a:n/a.
Jacobsson, A., Ek, Å., dan Akselsson, R. 2012. Learning from incidents - A method for assessing the effectiveness of the learning cycleJ. Loss Prev. Process Ind. 25:3, 561–570.
Jacobsson, A., Ek, A., dan Akselsson, R. 2011. Method for evaluating learning from incidents using the idea of “level of learning”J. LOSS Prev. PROCESS Ind. 24:4, 333–343.
Kerin, T. 2008. Learning from incidents - A practical application. Dipresentasikan pada AIChE Annual Meeting, Conference Proceedings.
Kim, E., dan Rhee, M. 2017. How airlines learn from airline accidents: An empirical study of how attributed errors and performance feedback affect learning from failureJ. Air Transp. Manag. 58, 135–143.
Kodate, N., Taneda, K., Yumoto, A., dan Kawakami, N. 2022. How do healthcare practitioners use incident data to improve patient safety in Japan? A qualitative studyBMC Health Serv. Res. 22:1.
Lafuente, E. 2024. Learning from different types of failure: evidence from non-severe and severe work accidents in SMEsSMALL Bus. Econ.
Lardner, R., dan Robertson, C.I. 2011. Towards a deeper level of learning from incidents: Use of scenarios. Dipresentasikan pada Institution of Chemical Engineers Symposium Series, hlm. 588–592.
Littlejohn, A., Margaryan, A., Vojt, G., dan Lukic, D. 2017. Learning from Incidents Questionnaire (LFIQ): The validation of an instrument designed to measure the quality of learning from incidents in organisationsSaf. Sci. 99, 80–93.
Lukic, D., Margaryan, A., dan Littlejohn, A. 2010a. How organisations learn from safety incidents: a multifaceted problemJ. Workplace Learn. 22:7, 428–450.
Lukic, D., Margaryan, A., dan Littlejohn, A. 2010b. How organisations learn from safety incidents: a multifaceted problemJ. Workplace Learn. 22:7, 428–450.
Manikumar, D., Raju, T.B., dan Sharma, U. 2024. Analysis of Accidents in the Oil and Gas Industry in KuwaitInt. J. Saf. Secur. Eng. 14:3, 893–905.
McClintock, A.H., Fainstad, T.L., dan Jauregui, J. 2021. Creating Psychological Safety in the Learning Environment: Straightforward Answers to a Longstanding ChallengeAcad. Med. 96:11S, S208.
Miranda, J., Todesco, J.L., Sell, D., de Medeiros, C., dan Potrich, L.N. 2024. Identifying Knowledge Flow in Complex Sociotechnical Systems to Contribute to Resilient Capacity: An Empirical Study. Dipresentasikan pada Proceedings of the European Conference on Knowledge Management, ECKM, hlm. 511–520.
Mohammadfam, I., Hamadan University of Medical Sciences, Soltanzadeh, A., Hamadan University of Medical Sciences, Moghimbeigi, A., Hamadan University of Medical Sciences, Akbarzadeh, M., dan Hamadan University of Medical Sciences. 2014. Factors affecting occupational accidents in the construction industry (2009-2013)J. Occup. Health Epidemiol. 3:2, 88–95.
Moher, D., Liberati, A., Tetzlaff, J., Altman, D.G., dan The PRISMA Group. 2009. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA StatementPLoS Med. 6:7, e1000097.
Muhren, W., Van Den Eede, G., dan Van De Walle, B. 2007. Organizational learning for the incident management process: Lessons from high reliability organizations. Dipresentasikan pada Proceedings of the 15th European Conference on Information Systems, ECIS 2007, hlm. 576–587.
Murphy, V.L., Littlejohn, A., dan Rienties, B. 2022. Learning from incidents: applying the 3-P model of workplace learningJ. Workplace Learn. 34:3, 242–255.
Nævestad, T.-O. 2008. Safety cultural preconditions for organizational learning in high-risk organizationsJ. Contingencies Crisis Manag. 16:3, 154–163.
Naot, Y., Lipshitz, R., dan Popper, M. 2004. Discerning the quality of organizational learningManag. Learn. 35:4, 451–472.
Noraishah Ismail, S., Ramli, A., dan Abdul Aziz, H. 2021. Research trends in mining accidents study: A systematic literature reviewSaf. Sci. 143, 105438.
Novatsis, E., McCormick, P., dan Lardner, R. 2012. Beyond bulletins and presentations: Use of scenarios to learn from incidents. Dipresentasikan pada Society of Petroleum Engineers - SPE/APPEA Int. Conference on Health, Safety and Environment in Oil and Gas Exploration and Production 2012: Protecting People and the Environment - Evolving Challenges, hlm. 673–678.
Page, M.J., Moher, D., Bossuyt, P.M., Boutron, I., Hoffmann, T.C., Mulrow, C.D., Shamseer, L., Tetzlaff, J.M., Akl, E.A., Brennan, S.E., Chou, R., Glanville, J., Grimshaw, J.M., Hróbjartsson, A., Lalu, M.M., Li, T., Loder, E.W., Mayo-Wilson, E., McDonald, S., McGuinness, L.A., Stewart, L.A., Thomas, J., Tricco, A.C., Welch, V.A., Whiting, P., dan McKenzie, J.E. 2021. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviewsBMJ 372, n160.
Paquay, M., Simon, R., Ancion, A., Graas, G., dan Ghuysen, A. 2023. A success story of clinical debriefings: lessons learned to promote impact and sustainabilityFront. PUBLIC Health 11.
Parker, A., Ummels, F., Wellman, J., Whitley, D., Groeneweg, J., dan Drupsteen, L. 2018. How to Take Learning from Incidents to the Next Level.
Patterson, C.M., Nurse, J.R.C., dan Franqueira, V.N.L. 2024. “I don’t think we’re there yet”: The practices and challenges of organisational learning from cyber security incidentsComput. Secur. 139.
Pilbeam, C., Davidson, R., Doherty, N., dan Denyer, D. 2016. What learning happens? Using audio diaries to capture learning in response to safety-related events within retail and logistics organizationsSaf. Sci. 81, 59–67.
Popay, J., Roberts, H., Sowden, A., Petticrew, M., Arai, L., Rodgers, M., Britten, N., Roen, K., dan Duffy, S. 2006. Guidance on the conduct of narrative synthesis in systematic reviews: A product from the ESRC Methods Programme. Lancaster University.
Provera, B., Montefusco, A., dan Canato, A. 2010. A “No Blame” Approach to Organizational LearningBr. J. Manag. 21:4, 1057–1074.
Radicchi, L.A., de Toledo, J.C., dan Alliprandini, D.H. 2020. Critical success factors for implementation of an incident learning system in radiation oncology departmentRep. Pract. Oncol. Radiother. 25:6, 994–1000.
Rossignol, N., dan van Oudheusden, M. 2017. Learning from Incidents and Incident Reporting: Safety Governance at a Belgian Nuclear Research CenterSci. Technol. Hum. Values 42:4, 679–702.
Russell Vastveit, K., Boin, A., dan Njå, O. 2015. Learning from incidents: Practices at a Scandinavian refinerySaf. Sci. 79, 80–87.
Sieberichs, S., dan Kluge, A. 2021. Why Commercial Pilots Voluntarily Report Self-Inflicted Incidents: A Qualitative Study with Aviation Safety ExpertsAviat. Psychol. Appl. Hum. Factors 11:2, 98–111.
Smith, V.C. 2007. A systems approach to strategic success with adjunct facultyNew Dir. Community Coll. 2007:140, 55–66.
Solberg, E., dan Bisio, R. 2022. Improving Learning by Adding the Perspective of Success to Event Investigations. Dipresentasikan pada Proceedings of the 32nd European Safety and Reliability Conference, ESREL 2022 - Understanding and Managing Risk and Reliability for a Sustainable Future, hlm. 1196–1203.
Stackhouse, M.R.D., dan Stewart, R. 2017. Failing to Fix What is Found: Risk Accommodation in the Oil and Gas IndustryRisk Anal. 37:1, 130–146.
Stemn, E., Bofinger, C., Cliff, D., dan Hassall, M.E. 2018. Failure to learn from safety incidents: Status, challenges and opportunitiesSaf. Sci. 101, 313–325.
Stemn, E., Hassall, M.E., dan Bofinger, C. 2020. Planning and implementing remedial measures from incident investigations: A study of the Ghanaian mining industrySaf. Sci. 127.
Sujan, M. 2015. An organisation without a memory: A qualitative study of hospital staff perceptions on reporting and organisational learning for patient safetyReliab. Eng. Syst. Saf. 144, 45–52.
van Marrewijk, A., dan van der Steen, H. 2024. Organizational learning from construction fatalities: Balancing juridical, ethical, and operational processesSaf. Sci. 174.
Vastveit, K.R., Orszak, M., Njå, O., dan Kraslawski, A. 2017. Learning from incidents at a Norwegian and a Polish refineryProcess Saf. Prog. 36:1, 102–108.
Wood, M.H., Koutelos, K., Hailwood, M., dan Cowley, C. 2022. Learning Lessons from Chemical Incidents - What’s Stopping Us and How We Can Make it HappenChem. Eng. Trans. 90, 685–690.
Chan, C.C.A. 2003. Examining the relationships between individual, team and organizational learning in an Australian hospitalLearn. Health Soc. Care 2:4, 223–235.
Chuang, Y.-T., Ginsburg, L., dan Berta, W.B. 2007. Learning from preventable adverse events in health care organizations: Development of a multilevel model of learning and propositionsHealth Care Manage. Rev. 32:4, 330–340.
Clare, J., dan Kourousis, K.I. 2021. Learning from Incidents in Aircraft Maintenance and Continuing Airworthiness Management: A Systematic ReviewJ. Adv. Transp. 2021, 1–13.
Cong, W., Xue, H., Liang, H., Su, Y., dan Zhang, S. 2022. Informal Safety Communication of Construction Workers: Conceptualization and Scale Development and ValidationFront. Psychol. 13, 825975.
Cooke, D.L., Dunscombe, P.B., dan Lee, R.C. 2007. Using a survey of incident reporting and learning practices to improve organisational learning at a cancer care centreQual. Saf. Health CARE 16:5, 342–348.
Cooke, D.L., dan Rohleder, T.R. 2006. Learning from incidents: from normal accidents to high reliabilitySyst. Dyn. Rev. 22:3, 213–239.
Dawson, R., Saulnier, T., Campbell, A., dan Godambe, S.A. 2022. Leveraging a Safety Event Management System to Improve Organizational Learning and Safety CultureHosp. Pediatr. 12:4.
de Kam, D., Grit, K., dan Bal, R. 2019. Shared learning from incidents: A qualitative study into the perceived value of an external chair on incident investigation committeesSaf. Sci. 120, 57–66.
De Kam, D., Grit, K., dan Bal, R. 2019. Shared learning from incidents: A qualitative study into the perceived value of an external chair on incident investigation committeesSaf. Sci. 120, 57–66.
De Wit, M., dan Peuscher, W. 2008. How well do companies embed learning from industrial incidents. Dipresentasikan pada Society of Petroleum Engineers - 9th International Conference on Health, Safety and Environment in Oil and Gas Exploration and Production 2008 - “In Search of Sustainable Excellence,” hlm. 256–263.
Doytchev, D., dan Hibberd, R.E. 2007. Organisational learning in industrial companies: Experiences from Germany. Dipresentasikan pada Proceedings of the European Safety and Reliability Conference 2007, ESREL 2007 - Risk, Reliability and Societal Safety, hlm. 1309–1317.
Drupsteen, L., Groeneweg, J., dan Zwetsloot, G.I.J.M. 2013. Critical Steps in Learning From Incidents: Using Learning Potential in the Process From Reporting an Incident to Accident PreventionInt. J. Occup. Saf. Ergon. 19:1, 63–77.
Drupsteen, L., dan Guldenmund, F.W. 2014. What Is Learning? A Review of the Safety Literature to Define Learning from Incidents, Accidents and DisastersJ. Contingencies Crisis Manag. 22:2, 81–96.
Edwin, K.W., Nilsen, M., dan Albrechtsen, E. 2021. Why Is the Construction Industry Killing More Workers Than the Offshore Petroleum Industry in Occupational Accidents?Sustainability 13:14, 7592.
Gardener, N.J.L. 2003. Safety improvement through learning from incidents. Dipresentasikan pada Institution of Chemical Engineers Symposium Series, hlm. 205–216.
Gray, D. 2010. Learning from Adverse Incidents: Using Action Research Cycles to Generate Individual and Organisational Knowledge.
Haunschild, P.R., Polidoro, F., Jr., dan Chandler, D. 2015. Organizational Oscillation Between Learning and Forgetting: The Dual Role of Serious ErrorsOrgan. Sci. 26:6, 1682–1701.
Hovden, J., Storseth, F., dan Tinmannsvik, R.K. 2011. Multilevel learning from accidents - Case studies in transportSaf. Sci. 49:1, 98–105.
Huber, S., van Wijgerden, I., de Witt, A., dan Dekker, S.W.A. 2009. Learning From Organizational Incidents: Resilience Engineering for High-Risk Process EnvironmentsPROCESS Saf. Prog. 28:1, 90–95.
Igić, D., Vuković, M., Urošević, S., Mladenović-Ranisavljević, I., dan Voza, D. 2021. The relationship between ethical leadership, organizational commitment and Zero Accident Vision implementation in the defense industryInt. J. Occup. Saf. Ergon. 27:4, 1076–1086.
Jacobsen, H.K., Ballangrud, R., dan Birkeli, G.H. 2024. Learning from patient safety incidents: The Green Cross methodNurs. Crit. Care n/a:n/a.
Jacobsson, A., Ek, Å., dan Akselsson, R. 2012. Learning from incidents - A method for assessing the effectiveness of the learning cycleJ. Loss Prev. Process Ind. 25:3, 561–570.
Jacobsson, A., Ek, A., dan Akselsson, R. 2011. Method for evaluating learning from incidents using the idea of “level of learning”J. LOSS Prev. PROCESS Ind. 24:4, 333–343.
Kerin, T. 2008. Learning from incidents - A practical application. Dipresentasikan pada AIChE Annual Meeting, Conference Proceedings.
Kim, E., dan Rhee, M. 2017. How airlines learn from airline accidents: An empirical study of how attributed errors and performance feedback affect learning from failureJ. Air Transp. Manag. 58, 135–143.
Kodate, N., Taneda, K., Yumoto, A., dan Kawakami, N. 2022. How do healthcare practitioners use incident data to improve patient safety in Japan? A qualitative studyBMC Health Serv. Res. 22:1.
Lafuente, E. 2024. Learning from different types of failure: evidence from non-severe and severe work accidents in SMEsSMALL Bus. Econ.
Lardner, R., dan Robertson, C.I. 2011. Towards a deeper level of learning from incidents: Use of scenarios. Dipresentasikan pada Institution of Chemical Engineers Symposium Series, hlm. 588–592.
Littlejohn, A., Margaryan, A., Vojt, G., dan Lukic, D. 2017. Learning from Incidents Questionnaire (LFIQ): The validation of an instrument designed to measure the quality of learning from incidents in organisationsSaf. Sci. 99, 80–93.
Lukic, D., Margaryan, A., dan Littlejohn, A. 2010a. How organisations learn from safety incidents: a multifaceted problemJ. Workplace Learn. 22:7, 428–450.
Lukic, D., Margaryan, A., dan Littlejohn, A. 2010b. How organisations learn from safety incidents: a multifaceted problemJ. Workplace Learn. 22:7, 428–450.
Manikumar, D., Raju, T.B., dan Sharma, U. 2024. Analysis of Accidents in the Oil and Gas Industry in KuwaitInt. J. Saf. Secur. Eng. 14:3, 893–905.
McClintock, A.H., Fainstad, T.L., dan Jauregui, J. 2021. Creating Psychological Safety in the Learning Environment: Straightforward Answers to a Longstanding ChallengeAcad. Med. 96:11S, S208.
Miranda, J., Todesco, J.L., Sell, D., de Medeiros, C., dan Potrich, L.N. 2024. Identifying Knowledge Flow in Complex Sociotechnical Systems to Contribute to Resilient Capacity: An Empirical Study. Dipresentasikan pada Proceedings of the European Conference on Knowledge Management, ECKM, hlm. 511–520.
Mohammadfam, I., Hamadan University of Medical Sciences, Soltanzadeh, A., Hamadan University of Medical Sciences, Moghimbeigi, A., Hamadan University of Medical Sciences, Akbarzadeh, M., dan Hamadan University of Medical Sciences. 2014. Factors affecting occupational accidents in the construction industry (2009-2013)J. Occup. Health Epidemiol. 3:2, 88–95.
Moher, D., Liberati, A., Tetzlaff, J., Altman, D.G., dan The PRISMA Group. 2009. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA StatementPLoS Med. 6:7, e1000097.
Muhren, W., Van Den Eede, G., dan Van De Walle, B. 2007. Organizational learning for the incident management process: Lessons from high reliability organizations. Dipresentasikan pada Proceedings of the 15th European Conference on Information Systems, ECIS 2007, hlm. 576–587.
Murphy, V.L., Littlejohn, A., dan Rienties, B. 2022. Learning from incidents: applying the 3-P model of workplace learningJ. Workplace Learn. 34:3, 242–255.
Nævestad, T.-O. 2008. Safety cultural preconditions for organizational learning in high-risk organizationsJ. Contingencies Crisis Manag. 16:3, 154–163.
Naot, Y., Lipshitz, R., dan Popper, M. 2004. Discerning the quality of organizational learningManag. Learn. 35:4, 451–472.
Noraishah Ismail, S., Ramli, A., dan Abdul Aziz, H. 2021. Research trends in mining accidents study: A systematic literature reviewSaf. Sci. 143, 105438.
Novatsis, E., McCormick, P., dan Lardner, R. 2012. Beyond bulletins and presentations: Use of scenarios to learn from incidents. Dipresentasikan pada Society of Petroleum Engineers - SPE/APPEA Int. Conference on Health, Safety and Environment in Oil and Gas Exploration and Production 2012: Protecting People and the Environment - Evolving Challenges, hlm. 673–678.
Page, M.J., Moher, D., Bossuyt, P.M., Boutron, I., Hoffmann, T.C., Mulrow, C.D., Shamseer, L., Tetzlaff, J.M., Akl, E.A., Brennan, S.E., Chou, R., Glanville, J., Grimshaw, J.M., Hróbjartsson, A., Lalu, M.M., Li, T., Loder, E.W., Mayo-Wilson, E., McDonald, S., McGuinness, L.A., Stewart, L.A., Thomas, J., Tricco, A.C., Welch, V.A., Whiting, P., dan McKenzie, J.E. 2021. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviewsBMJ 372, n160.
Paquay, M., Simon, R., Ancion, A., Graas, G., dan Ghuysen, A. 2023. A success story of clinical debriefings: lessons learned to promote impact and sustainabilityFront. PUBLIC Health 11.
Parker, A., Ummels, F., Wellman, J., Whitley, D., Groeneweg, J., dan Drupsteen, L. 2018. How to Take Learning from Incidents to the Next Level.
Patterson, C.M., Nurse, J.R.C., dan Franqueira, V.N.L. 2024. “I don’t think we’re there yet”: The practices and challenges of organisational learning from cyber security incidentsComput. Secur. 139.
Pilbeam, C., Davidson, R., Doherty, N., dan Denyer, D. 2016. What learning happens? Using audio diaries to capture learning in response to safety-related events within retail and logistics organizationsSaf. Sci. 81, 59–67.
Popay, J., Roberts, H., Sowden, A., Petticrew, M., Arai, L., Rodgers, M., Britten, N., Roen, K., dan Duffy, S. 2006. Guidance on the conduct of narrative synthesis in systematic reviews: A product from the ESRC Methods Programme. Lancaster University.
Provera, B., Montefusco, A., dan Canato, A. 2010. A “No Blame” Approach to Organizational LearningBr. J. Manag. 21:4, 1057–1074.
Radicchi, L.A., de Toledo, J.C., dan Alliprandini, D.H. 2020. Critical success factors for implementation of an incident learning system in radiation oncology departmentRep. Pract. Oncol. Radiother. 25:6, 994–1000.
Rossignol, N., dan van Oudheusden, M. 2017. Learning from Incidents and Incident Reporting: Safety Governance at a Belgian Nuclear Research CenterSci. Technol. Hum. Values 42:4, 679–702.
Russell Vastveit, K., Boin, A., dan Njå, O. 2015. Learning from incidents: Practices at a Scandinavian refinerySaf. Sci. 79, 80–87.
Sieberichs, S., dan Kluge, A. 2021. Why Commercial Pilots Voluntarily Report Self-Inflicted Incidents: A Qualitative Study with Aviation Safety ExpertsAviat. Psychol. Appl. Hum. Factors 11:2, 98–111.
Smith, V.C. 2007. A systems approach to strategic success with adjunct facultyNew Dir. Community Coll. 2007:140, 55–66.
Solberg, E., dan Bisio, R. 2022. Improving Learning by Adding the Perspective of Success to Event Investigations. Dipresentasikan pada Proceedings of the 32nd European Safety and Reliability Conference, ESREL 2022 - Understanding and Managing Risk and Reliability for a Sustainable Future, hlm. 1196–1203.
Stackhouse, M.R.D., dan Stewart, R. 2017. Failing to Fix What is Found: Risk Accommodation in the Oil and Gas IndustryRisk Anal. 37:1, 130–146.
Stemn, E., Bofinger, C., Cliff, D., dan Hassall, M.E. 2018. Failure to learn from safety incidents: Status, challenges and opportunitiesSaf. Sci. 101, 313–325.
Stemn, E., Hassall, M.E., dan Bofinger, C. 2020. Planning and implementing remedial measures from incident investigations: A study of the Ghanaian mining industrySaf. Sci. 127.
Sujan, M. 2015. An organisation without a memory: A qualitative study of hospital staff perceptions on reporting and organisational learning for patient safetyReliab. Eng. Syst. Saf. 144, 45–52.
van Marrewijk, A., dan van der Steen, H. 2024. Organizational learning from construction fatalities: Balancing juridical, ethical, and operational processesSaf. Sci. 174.
Vastveit, K.R., Orszak, M., Njå, O., dan Kraslawski, A. 2017. Learning from incidents at a Norwegian and a Polish refineryProcess Saf. Prog. 36:1, 102–108.
Wood, M.H., Koutelos, K., Hailwood, M., dan Cowley, C. 2022. Learning Lessons from Chemical Incidents - What’s Stopping Us and How We Can Make it HappenChem. Eng. Trans. 90, 685–690.
Published
2025-02-05
How to Cite
Raharjo, A., & Ariyanto, J. (2025). Memahami Proses Learning from Incident di Organisasi : Sistematik Literatur Review. urnal romotif reventif, 8(1), 1-16. https://doi.org/10.47650/jpp.v8i1.1678
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Articles
Copyright (c) 2025 Agung Raharjo, Januar Ariyanto
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