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.
> 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...
When failures happen, it's usually the organization rather than the individual that's key to changing.
Do you believe that people who vote for "tough on crime" prosecutors are seeking harsh punishment of mistakes?
Or do they want criminals acting in malice to have the book thrown at them so other people aren't needless victims?
Only a small subset of prosecutors elected in the most liberal districts are rewarded by their constituencies for exercising prosecutorial discretion. I say that without making any judgment as to whether they're using that discretion well — I'm just observing that very few prosecutors work that way.
Well, I think your position is probably one of ignorance. Plenty of people I talk to are for tough prosecution on things like violent crime and against tough prosecution for simple drug possession.
> Only a small subset of prosecutors elected in the most liberal districts are rewarded by their constituencies for exercising prosecutorial discretion. I say that without making any judgment as to whether they're using that discretion well — I'm just observing that very few prosecutors work that way.
Yes, that does seem to be a trend. Prosecutorial discretion is actually important, but it doesn't mean you let crime run rampant, either.
I don't live in a jurisdiction that elect prosecutors, but is this actually a thing? Do candidates/incumbents run campaign ads on their conviction rate? Are voters researching/talking about the conviction rate of the candidates like it's a pissing contest?
https://theintercept.com/2019/02/07/kamala-harris-san-franci...
> If the conviction rate had been measured by actual cases pursued, rather than all cases referred by police, Hallinan said, his office would have had a conviction rate that was relatively similar to Los Angeles and other major cities.
> And Hallinan was getting results. Overall, crime rates were plummeting. Violent crime had gone down close to 60 percent in San Francisco since Hallinan took office.
> Still, the low conviction rate resulted in headline after headline about San Francisco’s permissive attitude toward crime, a media environment harnessed by the Harris campaign.
From the article:
> Janie Harvey Garner, the founder of Show Me Your Stethoscope, a nursing group on Facebook with more than 600,000 members, worries the conviction will have a chilling effect on nurses disclosing their own errors or near errors, which could have a detrimental effect on the quality of patient care.
> "Health care just changed forever," she said after the verdict. "You can no longer trust people to tell the truth because they will be incriminating themselves."
That's the exact opposite of how the NTSB operates. It satisfies the infantile urge to blame and shame a supposed evildoer, to the great detriment of everybody in the long run.