The Blame Game

One major objective of a ‘Root Cause Analysis’ is to: ‘Look for improvements rather than apportion blame’

Recently, a tragic gas pipeline crossover resulted in death of a newborn, and left another with severe brain injury.

Prior to this incident many clinicians believed pipeline errors had been relegated to history. Unfortunately pipeline crossovers occur with relentless frequency (see here) – the RCA team may not have appreciated this. This affects the focus of their report – instead of finding solutions for preventing similar adverse events in the future they look at what could have stopped it in the past – a subtle difference and consequently the RCA recommendations appear like veiled forms of blame:

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