{
  "schema": "vedokrok.public-item.v1",
  "release_id": "MHC-RPUB-20260920-75ad787a",
  "url": "/knowledge/prefer-a-system-strengthening-action-over-another-reminder",
  "id": "MHC-D-RESEARCH-0733",
  "version": "0.1.0",
  "title": "Prefer a system-strengthening action over another reminder",
  "summary": "If the same slip can recur unchanged, the action probably did not reach the system.",
  "kind": "heuristic",
  "body": "Compare the proposed action with stronger options: remove the hazardous step, constrain invalid input, change the default, automate a check, improve visibility, reduce ambiguity or add recovery. Training can still be useful, especially for knowledge gaps, but do not use it as the automatic answer to a design defect.",
  "limits": [
    "Not every problem can be engineered away. Accountability, skill and judgment still matter; the point is not to misclassify a system defect as a memory problem."
  ],
  "topics": [
    "union-learning-from-decisions-and-errors"
  ],
  "intents": [],
  "source_ids": [
    "RS-C63447C9710D56FD"
  ],
  "evidence": [
    {
      "claim": "Modern RCA guidance emphasizes system-level contributing factors and sustainable corrective actions rather than stopping at individual blame or documentation.",
      "source_id": "RS-C63447C9710D56FD",
      "role": "supports",
      "note": "AHRQ discusses healthcare safety. The corpus transfers the system-design logic cautiously to ordinary work.",
      "locator": "Introduction; RCA2; action hierarchy discussion"
    }
  ],
  "use_when": [
    "The proposed fix is training, a policy reminder, a warning email or 'be more careful' after a repeatable failure."
  ],
  "avoid_when": [
    "Not every problem can be engineered away. Accountability, skill and judgment still matter; the point is not to misclassify a system defect as a memory problem."
  ],
  "example": "Instead of reminding analysts to check a file version, reject uploads whose schema version does not match the target.",
  "check": "The selected action changes the conditions under which the error occurs, or explicitly explains why that is not feasible.",
  "sources": [
    {
      "id": "RS-C63447C9710D56FD",
      "title": "The Evolution of Root Cause Analysis",
      "url": "https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis"
    }
  ],
  "relations": [],
  "collections": [
    {
      "id": "RC-D475A7021FD981F0",
      "title": "Turn mistakes and outcomes into changes you can verify",
      "url": "/collections/turn-mistakes-and-outcomes-into-changes-you-can-verify"
    }
  ]
}