Heuristic
Prefer a system-strengthening action over another reminder
If the same slip can recur unchanged, the action probably did not reach the system.
When it fits
- The proposed fix is training, a policy reminder, a warning email or 'be more careful' after a repeatable failure.
When to avoid it
- 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.
Why it matters
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.
An example
Instead of reminding analysts to check a file version, reject uploads whose schema version does not match the target.
Check your result
The selected action changes the conditions under which the error occurs, or explicitly explains why that is not feasible.
Keep this limit in mind
- 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.
Evidence and sources
Modern RCA guidance emphasizes system-level contributing factors and sustainable corrective actions rather than stopping at individual blame or documentation.
AHRQ discusses healthcare safety. The corpus transfers the system-design logic cautiously to ordinary work.
The Evolution of Root Cause Analysis · Introduction; RCA2; action hierarchy discussion