The US Forest Service (USFS) operates in a highly dynamic and high-risk environment. Changes can happen which can have catastrophic circumstances if they are not picked up. Unfortunately, sometimes things do go wrong and firefighters die or large amounts of property is lost. However, the USFS recognises that failure is a learning opportunity irrespective of what the outcome was. They also believe that exactly the same circumstances are unlikely to appear again so fixing that exact same problem will have limited impact on operations. However, there are probably other gaps in their safety protocols that need to be identified and fixed and that is the purpose of a Learning Review.
Given that we have so many ‘similar’ accidents, I believe that the same 'learning from failure' mindset should be developed within the healthcare community - that was the motivation for this article.
The US Forest Service (USFS) published a document in 2014* outlining how they undertake...
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