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Hey there. Thanks for this feedback. I think it is important to be open honest but not blame-oriented in our review of the situation. People make mistakes and that is okay, so long as they aren't willful or due to incompetence. Neither of which was the case here. The key thing is not to create a situation where a mistake is an individuals fault. My general view is if people are making mistakes then we have done something wrong as a company and need to understand and fix the tools/training/process that led to the mistake.


I'm involved in work around reviewing medical care.

Generally, a "People" section that mentions processes not being followed is an incomplete root cause analysis.

Why was it was possible for the process not to be followed?

There's obviously a limit to how far it makes sense to drill down with why why why, but stopping at "someone didn't follow guidance" is too early.




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