- Determine and rank the steps that should be taken to change the conditions that brought the incident in the first place.
- To keep the learning review focused, prioritize and discuss these action items in separate follow-up meetings with the relevant people.
- The facilitator must publish the learning review write-up as widely as possible. Both successes and failures should become part of institutional memory.
- If the incident negatively impacted people, consider using the 3 Rs to structure the writeup. The Rs stand for ‘Regret, Reason, and Remedy’ as it provides a straightforward formula for a meaningful, satisfying apology.
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