• Single and double-loop learning.
• Incident learning models.
• The least effective method of learning. 
• How to make a safety bulletin effective.
• Why organizational trust is a factor in learning.
• Why management is important to creating a culture of safety.
• Lessons Learned About Lessons Learned Systems.
• Practical takeaways.

1. a sociotechnical focus
2. improved data collection techniques
3. investigative independence
4. the professionalisation of investigators; and the aggregation of data.

Learning from incidents is key to maximising their preventative effectiveness, especially in an increasingly complex healthcare system.

The authors concluded that despite the ubiquity of incident investigation, there is a surprising lack of evidence concerning how recommendation generation is or should be undertaken. Little evidence is presented to show that investigations or recommendations result in improved care quality or safety. They suggest that although incident investigations remain foundational to patient safety, more enquiry is needed about how this important work is actually achieved and whether it can contribute to improving quality of care.

This paper will present extracts of the themed review template trialled and argues that thematic reviews, in this context, allowed for a better understanding of the system of safety around the mismanagement of the deteriorating patient.

Issue 12: Capacity and consent

Issue 11: Promoting sexual safety

Issue 10: Unsafe management of sepsis

Issue 9: Medicines management - assessment

Issue 8: Hypothermia

Issue 7: Falls from windows

Issue 6: Caring for people at risk of choking

Issue 5: Safe management of medicines - treatment

Issue 4: Burns from hot water or surfaces

Issue 3: Fire risk from use of emollient creams

Issue 2: Unsafe use of bed rails

Issue 1: Falls from improper use of equipment

Nine principles for incorporating human factors into learning investigations are identified:

1. Be prepared to accept a broad range of types and standards of evidence.

2. Seek opportunities for learning beyond actual loss events.

3. Avoid searching for blame.

4. Adopt a systems approach.

5. Identify and understand both the situational and contextual factors associated with the event.

6. Recognise the potential for difference between the way work is imagined and the way work is actually done.

7. Accept that learning means changing.

8. Understand that learning will only be enduring if change is embedded in a culture of learning and continuous improvement.

9. Do not confuse recommendations with solutions.