CareSet systems needs a Post Mortem process that is somewhere between the practices that happen inside hospitals and those common in the software and data engineering industry. In some cases, the Etsy guide has has some intensity reduced because it is not appropriate to pretend that lose of life can occur because of downtime for a consumer website. But for a healthcare technology company, our mistakes can cause harm to patients. We need something that has the context of the technology industry but also embraces the full weight of the Patient Safety movement.
In 2012, Esty wrote a post for the Code As Craft blog about how Esty approach learning from accidents and mistakes at Etsy. We wrote about the perspectives and concepts behind what is known (in the world of Systems Safety and Human Factors) as the New View on “human error.” Etsy also wrote about what it means for an organization to take a different approach, philosophically, to learn from accidents, and that Etsy was such an organization.
This Debriefing Facilitation Guide is an attempt to complement this blog post with a more practical guide about how Etsy approach learning from incidents in practice.
You can read more about the backstory of Etsy's work here and guide is available in markdown or PDF.