> understand that systems are complex. For what it's worth, this is not my experience. My experience is that there's often an attempt to assign blame to a smal

> understand that systems are complex. For what it's worth, this is not my experience. My experience is that there's often an attempt to assign blame to a small component of the system. My sense is it is ultimately to reduce effort or embarrassment, to blame whatever can be "fixed" with less work or indictment of "higher level" components. So the littler or less well-integrated person or more minor policy gets blamed over management or administration, or core operating policies, or culture, because the latter are harder to change or involve more admission of fundamental problems that could cause reputational harm. It's uncommon in my experience to acknowledge systemic problems or problems with very fundamental policies. My only criticism of the piece is that sometimes you can identify a root cause, but it's at a very high level of generality and/or involves an error of omission, which is harder to identify than an error of commission. For example, a policy or protocol that isn't present that could be.