# PWR-238 — Error reporting and learning: learner worksheet Release: Revision 7T · Full Tutorial Edition Estimated time: Estimated 27 min reading and worksheet pass Difficulty: Intermediate Equipment: Common household or practice equipment — Fictional near miss: an outdated paper script nearly gives a caller the wrong opening time.; Observation/report template, contributor map, action register, verification plan and reporter-feedback card.; v1 and v2 scripts, matched repeat-call cards and a second-reader check. Space: Desk / seated Automated structural checklist: 10 of 10 structural checks present Evidence quality/context: G1; Detailed research depth Automated method-quality band: Comprehensive Method-rating basis: Structure coverage, instruction/check specificity, alternative distinctness, source troubleshooting, comparison depth and whether purpose/check fields are authored rather than derived. Editorial review: Pending manual editorial sign off ## Before you begin - [ ] I read the tutorial authority and stop conditions. - [ ] I have the required equipment/space or a declared accessible alternative. ## Canonical source context This lesson teaches the complete error-learning loop. You will record direct observations, take only authorised immediate controls, route a fictional near miss, separate system contributors from blame, assign a corrective action, verify whether risk changed, report back and update current memory. Report count is not treated as learning. Target outcome: The learner completes a fictional near-miss record with observation, route, contributors, action owner, verification, reporter feedback and a demonstrated reduction in the matched repeat error. ### Authority and setup conditions - Label all materials fictional and keep them out of live reporting systems. - Write the legitimate real-world routes that would replace this exercise if an actual concern arose. - Separate immediate safety action, fact finding, contributor analysis and accountability roles. ### Required or supplied materials - Fictional near miss: an outdated paper script nearly gives a caller the wrong opening time. - Observation/report template, contributor map, action register, verification plan and reporter-feedback card. - v1 and v2 scripts, matched repeat-call cards and a second-reader check. ## 1. Record direct observations Write what was seen, heard or found, when and where; separate interpretations and unknowns. Why: Early blame labels narrow investigation before the observation timeline is complete. Success check: Another reader can distinguish fact, inference and missing information. Accessible alternative: Complete the same research action — “Write what was seen, heard or found, when and where; separate interpretations and unknowns.” — using speech-to-text, text-to-speech, enlarged text, keyboard-only navigation, shorter work blocks or a support person. Preserve this declared check: “Another reader can distinguish fact, inference and missing information.” Do not convert the research task into capability practice. Alternative relationship: Target preserving when declared check is preserved Learner notes: ________________________________________________________________________________ Completed: [ ] ## 2. Apply only authorised immediate control In the story, pause use of the outdated script and point users to the current source; do not improvise a wider intervention. Why: Immediate containment should reduce risk without prejudging cause. Success check: The specific exposure is controlled and action authority recorded. Accessible alternative: Replace small or visual-only information with enlarged text, high-contrast display, spoken description or tactile/verbal cueing while preserving the same decision and success check. Test that corrective actions and feedback remain accessible to the people who use and report the process. Alternative relationship: Target preserving when declared check is preserved Learner notes: ________________________________________________________________________________ Completed: [ ] ## 3. Route the report Use the fictional current channel, urgency and recipient; timestamp acknowledgement and preserve the reporter’s preferred contact. Why: A report that disappears cannot support learning. Success check: Named ownership and next update are recorded. Accessible alternative: Complete “Use the fictional current channel, urgency and recipient; timestamp acknowledgement and preserve the reporter’s preferred contact.” in shorter passes, or use keyboard input, dictation or a support person, while preserving this success check: “Named ownership and next update are recorded.” Offer private, asynchronous, spoken, written, AAC, interpreter and anonymous-if-officially-supported reporting routes. Alternative relationship: Target preserving when declared check is preserved Learner notes: ________________________________________________________________________________ Completed: [ ] ## 4. Map affected roles and prior signals Identify who could be affected, earlier similar reports, inaccessible routes and whether the issue could recur elsewhere. Why: A single event may reveal a broader condition. Success check: The scope is evidence-based, not assumed universal. Accessible alternative: Complete the same research action — “Identify who could be affected, earlier similar reports, inaccessible routes and whether the issue could recur elsewhere.” — using speech-to-text, text-to-speech, enlarged text, keyboard-only navigation, shorter work blocks or a support person. Preserve this declared check: “The scope is evidence-based, not assumed universal.” Do not convert the research task into capability practice. Alternative relationship: Target preserving when declared check is preserved Learner notes: ________________________________________________________________________________ Completed: [ ] ## 5. Analyse system contributors Examine version design, placement, update process, workload, training, incentives, supervision and interface conditions. Why: “Carelessness” rarely explains why an error was possible or repeated. Success check: At least three testable contributors are recorded. Accessible alternative: Complete “Examine version design, placement, update process, workload, training, incentives, supervision and interface conditions.” in shorter passes, or use keyboard input, dictation or a support person, while preserving this success check: “At least three testable contributors are recorded.” Test that corrective actions and feedback remain accessible to the people who use and report the process. Alternative relationship: Target preserving when declared check is preserved Learner notes: ________________________________________________________________________________ Completed: [ ] ## 6. Keep accountability distinct Mark whether conduct, competence or duty questions require an authorised process; do not decide them in the learning worksheet. Why: Systems analysis and accountability can coexist. Success check: No person is blamed or cleared without the proper role and evidence. Accessible alternative: Complete the same research action — “Mark whether conduct, competence or duty questions require an authorised process; do not decide them in the learning worksheet.” — using speech-to-text, text-to-speech, enlarged text, keyboard-only navigation, shorter work blocks or a support person. Preserve this declared check: “No person is blamed or cleared without the proper role and evidence.” Do not convert the research task into capability practice. Alternative relationship: Target preserving when declared check is preserved Learner notes: ________________________________________________________________________________ Completed: [ ] ## 7. Design the corrective action Choose an owner, resource, due date, expected effect, possible adverse effects and the exact mechanism changed. Why: “Remind staff” is often too weak and untestable. Success check: The action removes or controls the stale-version route. Accessible alternative: Complete “Choose an owner, resource, due date, expected effect, possible adverse effects and the exact mechanism changed.” in shorter passes, or use keyboard input, dictation or a support person, while preserving this success check: “The action removes or controls the stale-version route.” Do not require public confrontation, eye contact or immediate detailed disclosure. Alternative relationship: Target preserving when declared check is preserved Learner notes: ________________________________________________________________________________ Completed: [ ] ## 8. Verify with matched work Use a new fictional call card and cold user to test whether the current script is found and used; compare with baseline. Why: Completion status is not risk reduction. Success check: The repeat test measures the target error and unintended burden. Accessible alternative: Complete the same research action — “Use a new fictional call card and cold user to test whether the current script is found and used; compare with baseline.” — using speech-to-text, text-to-speech, enlarged text, keyboard-only navigation, shorter work blocks or a support person. Preserve this declared check: “The repeat test measures the target error and unintended burden.” Do not convert the research task into capability practice. Alternative relationship: Target preserving when declared check is preserved Learner notes: ________________________________________________________________________________ Completed: [ ] ## 9. Report back and update memory Tell the fictional reporter what changed and limits, update the current procedure, supersede old copies and set review. Why: Feedback and memory close the loop. Success check: Reporter, users and future staff can find the verified current state. Accessible alternative: Complete “Tell the fictional reporter what changed and limits, update the current procedure, supersede old copies and set review.” in shorter passes, or use keyboard input, dictation or a support person, while preserving this success check: “Reporter, users and future staff can find the verified current state.” Offer private, asynchronous, spoken, written, AAC, interpreter and anonymous-if-officially-supported reporting routes. Alternative relationship: Target preserving when declared check is preserved Learner notes: ________________________________________________________________________________ Completed: [ ] ## Reflection What changed? ________________________________________________________________________________ What remains difficult? ________________________________________________________________________________ What will I repeat, adapt, ask for help with, or stop? ________________________________________________________________________________ --- Completion of this worksheet demonstrates tutorial participation only. It does not establish capability, qualification, safety clearance, diagnosis, treatment or independent validation.