Sorry I was unclear. The distinction between "blame the pilot" and "determine root causes, so we can work to prevent recurrence", is relatively familiar in an

Sorry I was unclear. The distinction between "blame the pilot" and "determine root causes, so we can work to prevent recurrence", is relatively familiar in an aviation context. So say, a recurrent checklist failure, might prompt checklist improvement, rather than merely blaming pilots. Perhaps shortening a landing checklist, by moving items to a less tense approach checklist. So I attempted to illustrate by analogy, that describing a common reason why something happens, isn't being apologetic, or a distraction. Here, it seems possible that head-down engagement in physical manipulation, might have distracted from patient communication and care management. As that flavor of failure is not uncommon. Regards tech to reduce mistakes, it will be interesting to see AR attempt to blend medical records with point of care. To see the patient, is to see their status. To administer an injection, is to have it recorded. But yeah, culture change is core, and hard. And tech doesn't yet provide great leverage on that. Or sometimes, as with VA OR teams composed by randomized assignment, something non-ideal has been knowingly chosen for its larger-scale properties, and the tech task is to mitigate negative impact. By for instance, detecting when meds were requested, but absent a team familiar with working together, didn't happen. There was a VA trauma surgeon shopping around a request to implement that years back.