Systems. Errors.
If you've dealt with the Chemical Safety Board or the National Transportation Safety Board or any similar organization following an explosion or accident you know about their emphasis on systems and their reluctance to blame individuals for the events being investigated. Obviously, the working assumption that most errors are committed by good people trying to do the right thing has been a sound one and an emphasis on improving systems so those people can in fact do the right thing has yielded some impressive results. But you've likely asked yourself "does there ever come a point when everyone has been trained enough; when safety systems are redundant enough; when an individual needs to be held accountable rather than some unaccountable 'system'"? Apparently, at least in the case of medical errors, there does.
The New York Times is reporting on the growing concern that "a blame-free culture carries its own safety risks." When hand sanitizers are ubiquitous and training about hand sanitation is incessant, yet some doctors and nurses still fail to wash their hands something's wrong. And it's something, according to the researcher interviewed, that can't be fixed by tweaking the system. Someone has to be held accountable.
