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the attitude that "people need to be blamed" will never improve reliability in the long run. people come and go; systems and processes endure. blaming people is the best way to avoid making durable improvements to systems and processes.

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Doctors that make too many mistakes resulting in too high of payouts can't get individual malpractice insurance. Doctors that can't get individual malpractice insurance go to hospitals. Hospitals that hire too many doctors that make too many mistakes can't get hospital level policy. Hospital has to fire those doctors. That's how the system adjusts.

We do not have a system that adjusts to "oops"

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