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0 pointsPaulDavisThe1st4y ago0 comments

> That's the exact opposite of how the NTSB operates.

Bingo! I have a friend in the UK who organizes "post-mortem" (no pun intended) workshops and process training for hospital staff, precisely to do the NTSB-like thing after medical procedure errors occur. Rather than trying to point fingers and identify scapegoats, the central question is: "what went wrong here, and how do we reduce the chances of that happening again?"

Of course, occasionally the answer might be "We hired the wrong person, and we should fire them", but that seems to be only very rarely true.

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evil-olive4y ago

this is fairly common in the medical field, the usual name for it is "morbidity and mortality" [0]

> The objectives of a well-run M&M conference are to identify adverse outcomes associated with medical error, to modify behavior and judgment based on previous experiences, and to prevent repetition of errors leading to complications. Conferences are non-punitive and focus on the goal of improved patient care.

0: https://en.wikipedia.org/wiki/Morbidity_and_mortality_confer...

ethbr04y ago

An an organizational ethos, it's hard to argue with a default of "We fail, you succeed."

When failures happen, it's usually the organization rather than the individual that's key to changing.

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