"Whose fault is that? It’s the wrong question"
summary
Claims that blaming increases hidden errors and that more people in the U.S. die from preventable medical mistakes than from traffic accidents; contrasts two responses: aviation style root-cause investigation that documents every error, and medicine’s secrecy that hides them. Recommends replacing a blame culture with a learning culture plus a forgiving culture, using concrete actions: investigate failures, record causes (see TestAutomationPatterns.org pattern "learn from mistakes"), pardon the person so the team can learn and stop repeating the same errors.
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