Hey my personal soapbox was mentioned! So, I highly recommend the book Understanding Human Error by Sydney Deker if you’re interested in this sort of thing. He’s spent much of his career detailing how there’s not really such thing as an honest mistake or “human error” the way most people conceptualize it. There’s malicious actors, and there’s fallible humans interacting with imperfect systems. (There’s shades of maliciousness, obviously, like the difference between criminal recklessness and intentional murder, but ultimately either people choose, on some level, to make a bad decision, or they didn’t mean to make a ‘mistake’—a misnomer for when an imperfect system creates friction that imperfect humans must deal with, which leads to undesirable outcomes.)
A quintessential example can be found in medicine. Medication ‘errors’ are quite common, and rarely are they the result of anyone purposefully giving the wrong meds. Epinephrine, given most frequently in life-threatening emergencies, is one of the most commonly ‘errored’ meds because of a) the stress inherent to the situations that require it, and b) the massive difference in dilution-to-dosage ratio between methods of adminstration. You absolutely cannot push IV adrenaline in its undiluted 1:1,000 form—commonly found in large vials stocked in medical storage—because you will destroy people’s veins. 1:1,000 is for intramuscular usage, usually anaphylaxis. IV dilution is usually 1:10,000. But doing all that quick math in your head on the fly, while a patient is actively coding, means your godless monkey brain is fighting the part that needs to crunch a few numbers, dilute it right, and then adminster the damn thing. You can get really good at this, but even once in your whole career of fucking it up can kill a person, or harm them immensely. Add on what repeated stress of back-to-back 12 hr shifts does to response time, fine motor function, and memory—really it’s a wonder this doesn’t happen more than it does.
You know what’s most effective for reducing adrenaline dilution errors? Manufacturing pre-drawn syringes of properly diluted epinephrine that then get labelled IV EPINEPHRINE ONLY or IM EPINEPHRINE ONLY and color-coded in big fuck off red letters and caps so you can easily see and grab the right one with as little thought as possible. You know what would bring those numbers down even further? Staffing the fucking hospital properly.
Scapegoats are appealing because they’re more emotionally satisfying to blame than something like hospital schedules, or the medical-school-industrial-complex, or just the bad idea to make people do quick math while they’re working a code and searching for the right vials and syringes. This is so common you can find a dozen joke tiktoks about med dosage errors in your first 30 seconds on the app.
Absolutely people can be bigoted or malicious or lazy or uncaring—or all of them!—but that isn’t the same thing as making a ‘mistake.’ Mistakes are actually a sign that your system has a flaw, and that there needs to be an evaluation of what can be done better.
You mention aviation, and it’s funny but Deker’s work has mostly been taken into consideration by the airline industry over the years. Crew Resource Management (CRM) and things in that vein are the fundamentals of Deker’s work. Not to mention, the airline industry has a bit of an innoculation against scapegoating—in most plane crashes, the pilot(s) dies, and you can’t punish someone who’s already dead. A dead scapegoat doesn’t really perform its function.
Anyway, even the most compassionate people have a hard time truly letting go of scapegoating, even the people who believe in systemic reform have a hard time not taking the easy route and accepting a scapegoat. Because systemic reform is both hard and interpersonally unsatisfying. But you have to remember the fundamental purpose of the scapegoat: to divert blame. If you can’t actually find where the fault is, because fault has been assigned erroneously to the person deemed The Problem, the cracks will only widen.
