The Academic Learning Health System: A Framework for Integrating the Multiple Missions of Academic Medical Centers.

The learning health system (LHS) has emerged over the past 15 years as a concept for improving health care delivery. Core aspects of the LHS concept include: promoting improved patient care through organizational learning, innovation, and continuous quality improvement; identifying, critically assessing, and translating knowledge and evidence into improved practices; building new knowledge and evidence around how to improve health care and health outcomes; analyzing clinical data to support learning, knowledge generation, and improved patient care; and engaging clinicians, patients, and other stakeholders in processes of learning, knowledge generation, and translation. However, the literature has paid less attention to how these LHS aspects may integrate with the multiple missions of academic medical centers (AMCs). The authors define an academic learning health system (aLHS) as an LHS built around a robust academic community and central academic mission, and they propose 6 features that emphasize how an aLHS differs from an LHS. An aLHS capitalizes on embedded academic expertise in health system sciences; engages the full spectrum of translational investigation from mechanistic basic sciences to population health; builds pipelines of experts in LHS sciences and clinicians with fluency in practicing in an LHS; applies core LHS principles to the development of curricula and clinical rotations for medical students, housestaff, and other learners; disseminates knowledge more broadly to advance the evidence for clinical practice and health systems science methods; and addresses social determinants of health, creating community partnerships to mitigate disparities and improve health equity. As AMCs evolve, the authors expect that additional differentiating features and ways to operationalize the aLHS will be identified and hope this article stimulates further discussion around the intersection of the LHS concept and AMCs.

The Role of a Resilient Information Infrastructure in COVID-19 Vaccine Uptake in Ontario.

The COVID-19 pandemic has highlighted the need for a robust and nimble public health data infrastructure. ICES - a government-sponsored, independent, non-profit research institute in Ontario, Canada - functions as a key component of a resilient information infrastructure and an enabler of data co-production, contributing to Ontario's response to the COVID-19 pandemic as part of a learning health system. Linked data on the cumulative incidence of infection and vaccination at the neighbourhood level revealed disparate uptake between areas with low versus high risk of COVID-19. These data were leveraged by the government, service providers, media and the public to inform a more efficient and equitable vaccination strategy.

Características del proceso enseñanza aprendizaje vinculado al pensamiento crítico desde la mirada de docentes y estudiantes de enfermería / Characteristics of the Teaching-Learning Process Associated to Critical Thinking from the Perspective of Nursing Teachers and Students

Introducción: Enfermería incorpora en su formación de pregrado la competencia genérica y específica de pensamiento crítico y reflexivo, esencial para brindar cuidados holísticos. Objetivo: Describir características del proceso enseñanza aprendizaje vinculado a pensamiento crítico desde la mirada de docentes y estudiantes de la carrera de enfermería. Métodos: Estudio cualitativo descriptivo; realizado en la carrera de enfermería de la Universidad Católica del Norte; Chile, 2017. Las unidades de análisis se conformaron por 8 académicos y 12 estudiantes, seleccionados mediante muestreo por conveniencia, de acuerdo a objetivos, necesidades y alcance metodológico. Se utilizó la técnica de grupo focal. Se realizó análisis de contenido que dieron origen a matrices categoriales que emergen de los discursos. Resultados: El pensamiento crítico para académicos representa un proceso reflexivo complejo, importante para desarrollar habilidades integrales. Desde lo metodológico utilizan estrategias como: aprendizaje basado en problema, estudio de casos, simulaciones de baja y alta fidelidad, trabajo colaborativo, seminarios, clases interactivas, se enfatiza en la indagación; el proceso de evaluación se enmarca en lo oral y escrito, usando pautas y rúbricas. Conclusiones: La enseñanza de pensamiento crítico es compleja, proceso vital en la formación, los docentes y estudiantes construyen una percepción positiva del pensamiento crítico en el desarrollo del proceso enseñanza aprendizaje; emergen categorías: enseñanza del pensamiento crítico, entendida como progreso para favorecer el desarrollo de pensamiento reflexivo, metodologías, para favorecer el aprendizaje consciente de los estudiantes y evaluación del pensamiento crítico-reflexivo, entendido como mecanismos para profundizar logros de aprendizaje(AU)

Introduction: The Nursing major incorporates, in its undergraduate training program, the generic and specific competences of critical and reflective thinking, essential to providing holistic care. Objective: To describe the characteristics of the teaching-learning process associated to critical thinking from the perspective of teachers and students of the Nursing major. Methods: Descriptive and qualitative study carried out, in 2017, in the Nursing major of Universidad Católica del Norte, Chile. The analysis units were made up of eight scholars and twelve students, selected through convenience sampling, according to objectives, needs and methodological scope. The focus group technique was used. Content analysis was carried out, which gave rise to categorical matrices that emerge from the discourses. Results: Critical thinking for scholars represents a complex reflective process, important to developing comprehensive skills. From the methodological point of view, they use strategies such as problem-based learning, case studies, low and high fidelity simulations, collaborative work, seminars and interactive classes, while emphasis is placed on inquiry. The evaluation process is framed within oral and written activities, using guidelines and headings. Conclusions: The teaching of critical thinking is complex, a vital process in training. Teachers and students build a positive perception of critical thinking in the development of the teaching-learning process. Several categories emerge, such as teaching critical thinking, understood as progress to promote the development of reflective thinking; methodologies, to promote the conscious learning of students; and assessment of critical-reflective thinking, understood as mechanisms to deepen learning achievements(AU)

Learning From What We Do, and Doing What We Learn: A Learning Health Care System in Action.

Different models of learning health systems are emerging. At Vanderbilt University Medical Center, the Learning Health Care System (LHS) Platform was established with the goal of creating generalizable knowledge. This differentiates the LHS Platform from other efforts that have adopted a quality improvement paradigm. By supporting pragmatic trials at the intersection of research, operations, and clinical care, the LHS Platform was designed to yield evidence for advancing content and processes of care through carefully designed, rigorous study. The LHS Platform provides the necessary infrastructure and governance to leverage translational, transdisciplinary team science to inform clinical and operational decision making across the health system. The process transforms a clinical or operational question into a research question amenable to a pragmatic trial. Scientific, technical, procedural, and human infrastructure is maintained for the design and execution of individual LHS projects. This includes experienced pragmatic trialists, project management, data science inclusive of biostatistics and clinical informatics, and regulatory support. Careful attention is paid to stakeholder engagement, including health care providers and the community. Capturing lessons from each new study, the LHS Platform continues to mature with plans to integrate implementation science and to complement clinical and process outcomes with cost and value considerations. The Vanderbilt University Medical Center LHS Platform is now a pillar of the health care system and leads the evolving culture of learning from what we do and doing what we learn.

Online Communities as a Driver for Patient Empowerment: Systematic Review.

BACKGROUND: The use of online resources has changed how people manage health care processes. Patients seek information about health conditions, guidance in treatment, and support from peers online, complementary to traditional health care trajectories. Online communities have the potential to contribute to the quality of care by increasing patient empowerment; however, there is a gap in research regarding in what way online communities contribute to patient empowerment. OBJECTIVE: We synthesized research regarding how online communities contribute to patient empowerment to address the research question "In what ways can participation in online communities support patient empowerment?" by studying how patient empowerment is operationalized in different studies. The definition of patient empowerment used in this paper is enablement for people to develop mastery over actions and control over decisions that influence their lives. The mastery is both through processes and outcomes of the development. METHODS: A systematic review was conducted by searching in the following databases: Scopus, ACM Digital Library, EBSCO (CINAHL and MEDLINE), PubMed, and Web of Science. In total, there were 1187 papers after excluding duplicates, and through selection processes using an analytical framework with definitions of patient empowerment and related concepts, 33 peer-reviewed papers were included. RESULTS: Findings indicated that online communities support patient empowerment both as a process and as outcomes of these processes. Additionally, it was seen as a complement to traditional health care and encouragement for health care professionals to have a more positive attitude toward patients' usage. There was a mix between deductive (19/33, 58%), inductive (11/33, 33%), and a mixed approach (3/33, 9%) of studying patient empowerment in various forms. The online communities in most papers (21/33, 64%) were well-established and represented patients' initiatives. CONCLUSIONS: There is a need to include professionals' perspectives regarding how health care can embrace patient empowerment through online communities. This systematic review's main contribution is the proposal of a new framework and conceptualization of how patient empowerment in online communities can be understood from different hierarchical levels.

Embedding Learning in a Learning Health Care System to Improve Clinical Practice.

PROBLEM: In an ideal learning health care system (LHS), clinicians learn from what they do and do what they learn, closing the evidence-to-practice gap. In operationalizing an LHS, great strides have been made in knowledge generation. Yet, considerable challenges remain to the broad uptake of identified best practices. To bridge the gap from generating actionable knowledge to applying that knowledge in clinical practice, and ultimately to improving outcomes, new information must be disseminated to and implemented by frontline clinicians. To date, the dissemination of this knowledge through traditional avenues has not achieved meaningful practice change quickly. APPROACH: Vanderbilt University Medical Center (VUMC) developed QuizTime, a smartphone application learning platform, to provide a mechanism for embedding workplace-based clinician learning in the LHS. QuizTime leverages spaced education and retrieval-based practice to facilitate practice change. Beginning in January 2020, clinician-researchers and educators at VUMC designed a randomized, controlled trial to test whether the QuizTime learning system influenced clinician behavior in the context of recent evidence supporting the use of balanced crystalloids rather than saline for intravenous fluid management and new regulations around opioid prescribing. OUTCOMES: Whether spaced education and retrieval-based practice influence clinician behavior and patient outcomes at the VUMC system level will be tested using the data currently being collected. NEXT STEPS: These findings will inform future directions for developing and deploying learning approaches at scale in an LHS, with the goal of closing the evidence-to-practice gap.

Achieving Optimal Population Cardiovascular Health Requires an Interdisciplinary Team and a Learning Healthcare System: A Scientific Statement From the American Heart Association.

Population cardiovascular health, or improving cardiovascular health among patients and the population at large, requires a redoubling of primordial and primary prevention efforts as declines in cardiovascular disease mortality have decelerated over the past decade. Great potential exists for healthcare systems-based approaches to aid in reversing these trends. A learning healthcare system, in which population cardiovascular health metrics are measured, evaluated, intervened on, and re-evaluated, can serve as a model for developing the evidence base for developing, deploying, and disseminating interventions. This scientific statement on optimizing population cardiovascular health summarizes the current evidence for such an approach; reviews contemporary sources for relevant performance and clinical metrics; highlights the role of implementation science strategies; and advocates for an interdisciplinary team approach to enhance the impact of this work.

Equipes de aprendizagem ativa na educação em saúde: ensino-serviço-comunidade na prevenção da contaminação por Covid-19 / Active learning teams in health education: teaching-service-community for the prevention of Covid-19 / Equipos de aprendizaje activo en la educación en salud: enseñanza-serviciocomunidad en la prevención de la contaminación por Covid-19

Considerando o cenário mundial de pandemia do coronavírus, o presente estudo objetiva apresentar um modelo de formação para educação em saúde, constituído por Equipes de Aprendizagem Ativa (EAA), integrando ensino-serviço-comunidade para prevenção da contaminação por Covid-19. Esse modelo reúne nas EAA, supervisionadas por um docente, discentes da área da Saúde, professores e estudantes do ensino médio e agentes comunitários de saúde. O modelo proposto utiliza vídeos do Projeto Homem Virtual acerca do vírus SARS-CoV2 e pode ser ofertado nas modalidades remota, presencial ou híbrida. Assim, essa proposta de formação contribui para o enfrentamento da pandemia na perspectiva da educação em saúde. Ademais, a estruturação desse modelo permite que sua aplicabilidade seja versátil no que se refere às temáticas abordadas nos cursos, bem como no que diz respeito aos integrantes das EAA. (AU)

Against the backdrop of the coronavirus pandemic, this study presents an active learning teams (ALTs) training model for health education as part of teaching-service-community for the prevention of Covid-19 infection. Supervised by an academic staff member, the teams were made up of health students, high school teachers and students, and community health workers. The model uses videos from the Virtual Man Project about the SARS-CoV2 virus and can be offered in remote, face-to-face or hybrid formats. The training model contributes to the response to the pandemic in the field of health education. In addition, the model's versatile structure means it can be applied across different topics addressed by the courses and to different members of the ALTs. (AU)

Considerando el escenario mundial de pandemia del coronavirus, el presente estudio tiene el objetivo de presentar un modelo de formación, constituido por Equipos de Aprendizaje Activos (EAA), para Educación en Salud, integrando enseñanza-servicio-comunidad para prevención de la contaminación por Covid-19. Ese modelo reúne en las EAA, supervisadas por un docente, a discentes del área de la salud, profesores y estudiantes de la enseñanza media y agentes comunitarios de salud. El modelo propuesto utiliza vídeos del Proyecto Hombre Virtual sobre el virus SARS-CoV2 y puede ofrecerse en las modalidades remota, presencial o híbrida. Por lo tanto, esta propuesta de formación contribuye al enfrentamiento de la pandemia bajo la perspectiva de la Educación en salud. Además, la estructuración de este modelo permite que su aplicabilidad sea versátil en lo que se refiere a las temáticas abordadas en los cursos, así como en lo que se refiere a los integrantes de las EAA. (AU)

Estilos de aprendizaje y rendimiento académico en estudiantes de enfermería durante evaluaciones de simulación clínica / Learning styles and academic performance in nursing students during clinical simulation evaluations

Introducción: Los estilos de aprendizaje son rasgos cognitivos, afectivos y fisiológicos que indican como el estudiante percibe, interrelaciona y responde al ambiente de aprendizaje. La comprensión del propio estilo y la simulación realística permiten documentar la adquisición de competencias. Objetivo: Identificar la relación entre los estilos de aprendizaje y el rendimiento académico de estudiantes de primer año, carrera de enfermería en la asignatura primeros auxilios con simulación clínica. Métodos: Estudio de enfoque cuantitativo, diseño descriptivo correlacional. Se tomó una muestra de 68 estudiantes iniciales de la carrera de enfermería, Universidad Finis Terrae, en el segundo semestre de 2017, con un muestreo por conveniencia, de un universo de 75 estudiantes; se midieron los estilos de aprendizaje con los instrumentos de CHAEA y Kolb, validados en Chile. Se evaluó el rendimiento con notas de prueba y talleres de simulación. Para el análisis estadístico se usó el Coeficiente de Correlación de Pearson. Resultados: El 80,88 por ciento de los estudiantes son mujeres, edad promedio 19,5 años y un 17,65 por ciento trabaja. El promedio de notas del taller Reanimación Cardio Pulmonar fue de 6,29 (Escala 1-7), del taller de simulación clínica integrado fue de 6,27 y de la prueba teórica fue 5,6. Predominaron en los estudiantes un estilo pragmático (52,80 por ciento en alto y muy alto) y teórico (66,10 por ciento en alto y muy alto) según Honey Alonso; y asimiladores y acomodadores según Kolb. Conclusión: Se observó que hubo correlación entre los estilos de aprendizaje y el rendimiento académico y que la experiencia activa con simulación mejoró las calificaciones de los estudiantes(AU)

Introduction: Learning styles are cognitive, affective, and physiological features that indicate how the student perceives, interrelates, and responds to the learning environment. Understanding your own style and realistic simulation allow you to document the acquisition of skills. Objective: To identify the relation between learning styles, learning achievements and academic performance in first year students in first aid subject with clinical simulation, nursing career, Finis Terrae University, 2017. Methods: Quantitative approach, descriptive correlational design. A sample of 68 initial nursing students was taken in the second semester of 2017, with a convenience sampling, from a universe of 75 students; Learning styles were measured with the CHAEA and Kolb instruments, validated in Chile. Performance was assessed with test notes and simulation workshops. Pearson Correlation Coefficient was used for statistical analysis. Results: 80,88 percent of the students are women, average age 19,5 years and 17,65 percent work. The average marks of the Cardiopulmonary Resuscitation workshop were 6,29 (Scale 1-7), the integrated clinical simulation workshop was 6,27 and the theoretical test was 5,6. Students predominate in a pragmatic (52,80 percent) and theoretical (66,10 percent) style according to Honey Alonso, and assimilators and ushers according to Kolb. Discussion: It was observed that there is a correlation between learning styles and academic performance, and active simulation experience improves student performance(AU)

Methods to identify and prioritize research projects and perform embedded research in learning healthcare systems.

BACKGROUND: The Embedded Healthcare Research Conference aimed to promote and enhance research-operations partnerships in diverse health care settings. Within this conference, the Priorities and Methods Workgroup set out to define a vision of embedded research that leverages diverse methods to address clearly articulated research questions of importance to health systems. METHODS: The Workgroup session involved a combination of small and large group discussions around three broadly focused topics: the integration of embedded research within the existing quality improvement (QI) ecosystem; the identification, prioritization and formulation of embedded research questions; the creation of an embedded research "tool kit." RESULTS: Workgroup participants envisioned a future for embedded research that is characterized by authentic engagement between researchers and health system leaders; seamless integration between research, QI and clinical operations; clear and explicit articulation of research questions; an appropriate balance between rigor and relevance in applied methodology; alignment between study design, available resources and the importance of the knowledge to be gained; efficient processes; and bi-directional communication. Important barriers to achieving this vision include limited access to executive leaders, silos that discourage integration of research and QI, generally low tolerance for disruption in high-risk clinical settings, limited access to data, and limited availability of researchers with requisite skills and training. CONCLUSIONS: Embedded research holds potential to enhance the relevance, value and use of research, while also creating generalizable knowledge. Key recommendations include building authentic relationships, discouraging silos, encouraging innovation and experimentation, and expanding opportunities for funding research in delivery systems.

Can Electronic Health Records Validly Estimate the Effects of Health System Interventions Aimed at Controlling Body Weight?

OBJECTIVE: This study aimed to compare weight collected at clinics and recorded in the electronic health record (EHR) with primary study-collected trial weights to assess the validity of using EHR data in future pragmatic weight loss or weight gain prevention trials. METHODS: For both the Track and Shape obesity intervention randomized trials, clinic EHR weight data were compared with primary trial weight data over the same time period. In analyzing the EHR weights, intervention effects were estimated on the primary outcome of weight (in kilograms) with EHR data, using linear mixed effects models. RESULTS: EHR weight measurements were higher on average and more variable than trial weight measurements. The mean difference and 95% CI were similar at all time points between the estimates using EHR and study-collected weights. CONCLUSIONS: The results of this study can be used to help guide the planning of future pragmatic weight-related trials. This study provides evidence that body weight measurements abstracted from the EHR can provide valid, efficient, and cost-effective data to estimate treatment effects from randomized clinical weight loss and weight management trials. However, care should be taken to properly understand the data-generating process and any mechanisms that may affect the validity of these estimates.

Characteristics, Symptom Severity, and Experiences of Patients Reporting Chronic Kidney Disease in the PatientsLikeMe Online Health Community: Retrospective and Qualitative Study.

BACKGROUND: Chronic kidney disease (CKD) is a major global health burden, and is associated with increased adverse outcomes, poor quality of life, and substantial health care costs. While there is an increasing need to build patient-centered pathways for improving CKD management in clinical care, data in this field are scarce. OBJECTIVE: The aim of this study was to understand patient-reported experiences, symptoms, outcomes, and treatment journeys among patients with CKD through a retrospective and qualitative approach based on data available through PatientsLikeMe (PLM), an online community where patients can connect and share experiences. METHODS: Adult members (aged ≥18 years) with self-reported CKD within 30 days of enrollment, who were not on dialysis, and registered between 2011 and 2018 in the PLM community were eligible for the retrospective study. Patient demographics and disease characteristics/symptoms were collected from this retrospective data set. Qualitative data were collected prospectively through semistructured phone interviews in a subset of patients, and questions were oriented to better understand patients' experiences with CKD and its management. RESULTS: The retrospective data set included 1848 eligible patients with CKD, and median age was 56 years. The majority of patients were female (1217/1841, 66.11%) and most were US residents (1450/1661, 87.30%). Of the patients who reported comorbidities (n=1374), the most common were type 2 diabetes (783/1374, 56.99%), hypertension (664/1374, 48.33%), hypercholesterolemia (439/1374, 31.95%), and diabetic neuropathy (376/1374, 27.37%). The most commonly reported severe or moderate symptoms in patients reporting these symptoms were fatigue (347/484, 71.7%) and pain (278/476, 58.4%). In the qualitative study, 18 eligible patients (13 females) with a median age of 60 years and who were mainly US residents were interviewed. Three key concepts were identified by patients to be important to optimal care and management: listening to patient needs, coordinating health care across providers, and managing clinical care. CONCLUSIONS: This study provides a unique source of real-world information on the patient experience of CKD and its management by utilizing the PLM network. The results reveal the challenges these patients face living with an array of symptoms, and report key concepts identified by patients that can be used to further improve clinical care and management and inform future CKD studies.

Status Update on Data Required to Build a Learning Health System.

Wide adoption of electronic health records (EHRs) has raised the expectation that data obtained during routine clinical care, termed "real-world" data, will be accumulated across health care systems and analyzed on a large scale to produce improvements in patient outcomes and the use of health care resources. To facilitate a learning health system, EHRs must contain clinically meaningful structured data elements that can be readily exchanged, and the data must be of adequate quality to draw valid inferences. At the present time, the majority of EHR content is unstructured and locked into proprietary systems that pose significant challenges to conducting accurate analyses of many clinical outcomes. This article details the current state of data obtained at the point of care and describes the changes necessary to use the EHR to build a learning health system.

An Analysis of the Learning Health System in Its First Decade in Practice: Scoping Review.

BACKGROUND: In the past decade, Lynn Etheredge presented a vision for the Learning Health System (LHS) as an opportunity for increasing the value of health care via rapid learning from data and immediate translation to practice and policy. An LHS is defined in the literature as a system that seeks to continuously generate and apply evidence, innovation, quality, and value in health care. OBJECTIVE: This review aimed to examine themes in the literature and rhetoric on the LHS in the past decade to understand efforts to realize the LHS in practice and to identify gaps and opportunities to continue to take the LHS forward. METHODS: We conducted a thematic analysis in 2018 to analyze progress and opportunities over time as compared with the initial Knowledge Gaps and Uncertainties proposed in 2007. RESULTS: We found that the literature on the LHS has increased over the past decade, with most articles focused on theory and implementation; articles have been increasingly concerned with policy. CONCLUSIONS: There is a need for attention to understanding the ethical and social implications of the LHS and for exploring opportunities to ensure that these implications are salient in implementation, practice, and policy efforts.

Teaching Systems Improvement to Early Medical Students: Strategies and Lessons Learned.

PURPOSE: Despite increasing emphasis in medical school education on quality and systems improvement, many medical schools lack sufficient faculty with expertise to teach systems improvement. Using the pedagogical content knowledge framework, this study explores how faculty engage students in systems improvement work and faculty perceptions of the outcomes for the health system and students. METHOD: In May-June 2017, the authors interviewed 12 of 13 invited faculty with experience in teaching and engaging first-year medical students in systems improvement work, the course of students' systems improvement work over time, the impact of students' projects on health systems, and students' learning and attitudes about systems improvement. The authors conducted qualitative analysis iteratively with data collection to sufficiency. RESULTS: Six emergent themes characterized faculty's approach to guiding students in systems improvement work: faculty-student relationship, faculty role, student role, faculty-student shared responsibility for projects, faculty and student content knowledge, and project outcomes. The faculty-student relationship was foundational for successful systems improvement work. Faculty roles included project selection, project management, and health systems interactions. Students engaged in systems improvement as their faculty leveraged their knowledge and skills and created meaningful student roles. Faculty and students shared responsibility and colearned systems improvement content knowledge. Faculty defined successful outcomes as students' learning about the systems improvement process and interprofessional collaboration. CONCLUSIONS: Findings highlight the critical importance of pedagogical content knowledge to engage early learners in systems improvement work, understand their learning interests and needs, and manage their projects longitudinally.

Learning From Incident Reporting? Analysis of Incidents Resulting in Patient Injuries in a Web-Based System in Swedish Health Care.

OBJECTIVES: Incident reporting (IR) systems have the potential to improve patient safety if they enable learning from the reported risks and incidents. The aim of this study was to investigate incidents registered in an IR system in a Swedish county council. METHODS: The study was conducted in the County Council of Östergötland, Sweden. Data were retrieved from the IR system, which included 4755 incidents occurring in somatic care that resulted in patient injuries from 2004 to 2012. One hundred correctly classified patient injuries were randomly sampled from 3 injury severity levels: injuries leading to deaths, permanent harm, and temporary harm. Three aspects were analyzed: handling of the incident, causes of the incident, and actions taken to prevent its recurrence. RESULTS: Of the 300 injuries, 79% were handled in the departments where they occurred. The department head decided what actions should be taken to prevent recurrence in response to 95% of the injuries. A total of 448 causes were identified for the injuries; problems associated with procedures, routines, and guidelines were most common. Decisions taken for 80% of the injuries could be classified using the IR system documentation and root cause analysis. The most commonly pursued type of action was change of work routine or guideline. CONCLUSIONS: The handling, causes, and actions taken to prevent recurrence were similar for injuries of different severity levels. Various forms of feedback (information, education, and dialogue) were an integral aspect of the IR system. However, this feedback was primarily intradepartmental and did not yield much organizational learning.