The STARS approach includes change by SHOCK: whenever faced by a crisis the ability to recognise the event as an opportunity to learn and implement new ways of organising. This intervention strategy requires a slightly different way of incident review and follow up.
Serious incidents invite reflection and review of practices - and the way this review is set up has important ramifications for learning from these unwanted events. Even to the extent that a crisis becomes a crucial imperative for change and innovation.
This intervention strategy starts with the key people that investigate near-misses, incidents or even disasters. The composition, method and framework of these teams and their investigation process are all crucial in using unwanted events and capitalise on larger lessons learnt.
Intervention techniques here are manifold - and all require considerable expertise and experience. Incident reviews are often directed at understanding the cause and effect of the event at hand. We offer complementary techniques such as "what if" analysis and "error inducing" analysis to support follow up on investigations.