[coalescence]

With #3 - ideally your systems should not allow you to break established procedure. Mitigate the risk by not giving the support staff tools to shoot yourself in the foot so easily. This could be achieved with peer verification or some other mechanism (lots of ways if you think it through).

[tamar]

Yes, learning experiences are had when things happen like this. We look to the future, not to the past, to ensure the same mistakes do not recur.