[jdietrich]

There's no such thing as an "individual error" - every individual is operating within a management structure. Every error has the chance to be prevented before the fact or mitigated after the fact by proper quality management. Even if that individual is a lazy idiot who shouldn't be trusted with pointy scissors, whose fault is it for hiring him?

All errors exist on a spectrum of foreseeability and severity. Is it foreseeable that someone might miss a spot when cleaning? Yes, clearly, even if they're exceptionally diligent and well trained. The odds of them making that error diminish with training, skill and care, but they never reach zero. How severe are the likely consequences of that error? In this case, someone could die of sepsis.

You can't just shrug and say "the guy who was supposed to clean the device didn't do it properly, it's not our fault". Why did that error happen? What could management have done to reduce the probability of that error? How could that error have been detected before a patient was put at risk? From reading the story, I think it's abundantly clear that many opportunities to reduce risk are being missed due to poor management of the process.

[b_tterc_p]

You’re saying that management can influence events and that’s true. But management can minimize risk to more than acceptable levels and the individual can still screw up due to their own folly. This really feels like a dumb argument, that your mistakes must be the result of higher order systems.

[smallnamespace]

Are you willing to extend the 'no such thing as individual error' philosophy to management as well?

Managers also exist inside a structure, one which they may not have created themselves, or where they lack power to make unilateral changes. Managers also often work inside highly competitive environments (e.g. capitalism) where much deviation from the current norm can be disastrous for both the organization and themselves.

At some point, any practical moral philosophy needs to direct some individual to change their actions. Morality without responsibility is powerless.

[jdietrich]

> Are you willing to extend the 'no such thing as individual error' philosophy to management as well?

Ultimately it's the CEO's responsibility to lead a culture of safety. If the current norm is causing death and illness, it's their moral duty to push back against it.

[b_tterc_p]

Ok but the question isn’t about a norm of death and illness, it’s about a single one off individual error