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Never say never again: post-incident change and the investigation trap

Professor David A. Buchanan, Visiting rofessor of Organisational Behaviour

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Public lectures | Seminars

Never Say never again: post incident change and the investigation trap.

  • From: Wednesday 11 June 2014, 12 am
  • To: Wednesday 11 June 2014, 12 am
  • Location: N45, Newton building, Main Entrance, Nottingham Trent University, City Campus, Goldsmith Street, Nottingham, NG1 4BU
  • Booking deadline: Saturday 10 June 2017, 12.00 am
  • Download this event to your calendar

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Event details

The problem

Why would organisations not implement change following accidents, crises, and disasters, in order to prevent further similar incidents? This is a setting in which it might be assumed that change would be welcome, automatic, straightforward. Expectations and receptiveness should be high, resistance low. The evidence shows, however, that these assumptions are often incorrect. After losing the shuttle Challenger, how could NASA have lost Columbia? Following the death of Victoria Climbié, how could Haringey Children's Services and other agencies have failed Peter Connelly?

The research

This seminar explores the problems of post-incident change by considering the recommendations that flowed from a number of serious patient safety incidents (known as 'never events') in a hospital operating theatres department. These kinds of incidents offer an 'audit' of an organisation's procedures and practices, a 'window on the system', that potentially opens new avenues for change and development. Information was gathered from interviews, extensive documentation, a theatres team workshop, and a debriefing for hospital staff involved in the events.

The findings

Analysis of these incidents and the sequence of events that followed shows how reporting and investigation procedures impede the changes that they are designed to encourage. Institutional regulations and protocols in this case generated a path dependent process, locking the organisation into relatively simple actions which could be addressed quickly, and overlooking wider and potentially more significant systemic changes. Post-incident change was caught in an 'investigation trap', sprung by external demands and internal procedures. Measures for avoiding this trap are identified, in the interests of organisation development, and improved patient safety.

About the author:

David is Emeritus Professor of Organisational Behaviour at Cranfield University School of Management, and Visiting Professor at Nottingham Business School. He also works as an independent consultant and author, specialising in change management and organisation politics. He has a Doctorate in Organisational Behaviour from Edinburgh University, was Director of Loughborough University Business School from 1992 to 1995, has held visiting posts in Australian and Canadian management schools, and works regularly in Australia and Sweden.

He is author / co-author of over two dozen books, including the best-selling text, Organizational Behaviour (with Andrzej Huczynski; eighth edition 2013), and The Sage Handbook of Organizational Research Methods (with Alan Bryman, paperback 2011). He has co-authored several books on change management, including: Take The Lead and The Expertise of the Change Agent (with David Boddy), The Sustainability and Spread of Organizational Change (with Louise Fitzgerald and Diane Ketley), and Power, Politics and Organizational Change: Winning the Turf Game (with Richard Badham). He has also written numerous book chapters, papers, and articles on organisational behaviour and change.

Booking information

Please book your place by emailing Suzanne Ross

Places are limited, so we recommend booking your place on this seminar as early as possible to avoid disappointment.

Location details


N45, Newton building, Main Entrance


Nottingham Trent University
City Campus
Goldsmith Street

Past event

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