When Lessons Learnt are Lessons Lost

Over 400 years ago, Captain James Lancaster, an English sailor, performed a benchmark experiment in his pursuit of a prevention for a disease called scurvy.  Scurvy was one of the biggest problems at sea at that time, killing or debilitating many individual sailors as well as rendering the operational capability of a crew so diminished that the remaining sailors struggled to man their ships safely. 
 
On just one of four ships in a flotilla bound for India Capt. Lancaster prescribed three teaspoons of lemon juice a day for the entire crew.  By the half way point of the journey everyone on that ship was alive and well. On the other 3 craft, 110 men out of 278 (40%) had died and others were becoming increasingly weak and sick.


 
This was an incredible finding that directly linked scurvy, a killer disease, with a chronic lack of Vitamin C.  It revealed that relatively modest consumption of lemon juice was a way of avoiding hundreds of needless deaths on future journeys as well as the loss of millions of pounds (in today’s money) of ships and naval hardware.      
 
Despite this discovery, it was to take another 200 years (and thousands more unnecessary deaths) for the British Royal Navy to enact firm dietary guidelines as routine on its ships. This is an adoption rate that can only be described as a ‘glacial’. 
 
One would hope that things have changed and moved on since then, however, many large organisations still struggle to analyse their mistakes and learn from them. And for some, even when learning is identified, these learning opportunities don’t easily flow through the system to the ‘front line’.  For example, adoption rates in global healthcare, in particular, are known for being ‘low and slow’ and have been described as universally sluggish for many years. One recent study examined the outcomes of nine major medical discoveries made at the end of the 20^thcentury. The study revealed it took an average of 17 years before the new treatments were fully adopted by the majority of doctors.
 
But even in this ‘information age’ many differing organisations and sectors continue to struggle with implementing important ‘lessons learnt’. multiple studies clearly show that adoption rates are directly linked to the way that important learning is formatted and distributed to relevant parties. Revealing that necessary knowledge has often not been translated into a simple, usable and systematic format.
 
Now, although it should be noted that direct comparison between different sectors should be handled with extreme caution, the aviation industry is regularly presented as a sector that has worked assiduously on this issue of sharing learning. Examples being;
 

1. In aviation in the aftermath of an investigation the report is made available to everyone. 
2. Airlines have a legal responsibility to implement the recommendations. 
3. Every pilot in the world has free access to the data 
4. Aviation has protocols that enable every airline, pilot and regulator to access every new piece of information in almost real time.