Blogger's Note: Steven Lewis is always worthwhile reading, this particular essay discusses several widely known national traumatic events of which harm was caused to many due to system failures, in part; Longwoods Publishing (sometimes) requires registration (free/sometimes free)
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This Just In: Systems Designed to Fail, Fail
Steven Lewis
"First there is the disaster that comes to light long after the fact. Then there is the inquiry. Then there is the scathing report that meticulously unearths the causes of the disaster. Then there is the apology (they're allowed now - it's the law!). Then there is restitution. Finally there is the commitment: never again. And then the same thing happens, somewhere else, again, and again, and again....."
"It is delusional to believe that everything is now out in the open, with nothing more to uncover. It's not just the outliers who cause harm; because medicine is so fraught with unjustifiable variations in practice, it is certain that the errors resulting from "satisfactory" practice far outnumber the misdeeds of the visibly incompetent. The graveyards are filled with anonymous victims whose stories will never surface in a public inquiry."
