Systems Thinking-Point

I'm reading through Farnam Street  past articles, when I come across this piece, interviewing Risky Business: James Bagian—NASA astronaut turned patient safety expert—on Being Wrong .

What catches my attention is the opening question and his answer:

How does the healthcare industry compare to engineering and aeronautics when it comes to dealing with human error?
Not favorably. Much of my background is in what's called high-reliability industries—the ones that operate under conditions of high hazard yet seldom have a bad event—and people in those fields tend to have a systems perspective. We're not terribly interested in what some individual did. We want to know what led up to a bad event and what changes we need to make to reduce the likelihood of that event ever happening again.
When I got into healthcare, I felt like I'd stepped into an entirely different world. It was all about, "Let's figure out who screwed up and blame them and punish them and explain to them why they're stupid." To me, it's almost like whistling past the grave. When we demonize the person associated with a bad event, it makes us feel better. It's like saying, "We're not stupid so it won't happen to us." Whereas in fact it could happen to us tomorrow.
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The key point here of course is "systems perspective". Systems perspective doesn't look to blame the individual. People can not work to their full potential if they're worried about mistakes, and being the scape goat. It fosters a poison culture.
Systems perspective is about improvement, not blame. It's a process that will over time produce better, more consistent results. Talent prospers in such a system.