2.1. Ad Hoc Approach
In any system—industry, organization, or setting—where error is common, there are many ways in which error reduction may be approached. One approach assumes that if people (engineers, doctors, specialists, technicians, operators, professionals, educationists, service providers, etc.) are more careful, pay more attention, and in general adopt more rigor in what they are doing then errors can be reduced and their effects mitigated. This approach particularly applicable at first two levels of system errors and failures there from tends to put great emphasis on the psychology of the individual who makes the error and on training, admonition, supervision, and ever-tighter and more detailed rules, with an implication of blame attached to those who make errors. That is to say, the error problem is seen as of that moment having no significance beyond itself. This approach, ad-hoc in nature, puts whole attention after a particular error. In real world, the error, however, does not occur again in the same form and in a same situation in a linearly predicted manner. Also, although people—engineers, doctors, specialists, technicians, etc.—are arguably among the most careful people in our society, they make mistakes. As a result, this approach, easier to pursue, gives a false sense of having taken steps for error removal. It never minimizes the error occurrence, though, and is invariably found less effective and more costly in the long run.
2.2. Integrity-Based Holistic, Systemic Approach
In contrast to the above there is a second approach—holistic and systemic—that sees the design of system elements, namely, objects (machines as well as concepts, e.g., design basis, budget), people, communication, software, norms (practices, standards, long-held beliefs), rules, procedures, behavior, policy, financial mechanism, etc. as being the source of errors. This approach emphasizes that people of good intention, skilled and experienced, may nonetheless be forced to commit errors by the way in which their behavior is impacted by interdependent, evolving, conflicting, and otherwise non-critical environmental factors. One need not deny that the most recognized system element, namely, people make errors because of fatigue, carelessness, or lack of training in order to espouse this approach to error. Similar observation is valid for errors in each of the other well-implemented system elements (objects, communication, software, norms, etc.) mentioned above. The fundamental hypothesis is that systems of which above elements are a part call forth errors from elements, not the other way around. Only as an attribution of last resort, or because of the tendency of a traditional, hierarchical management to be less concerned with integrity, i.e., correctness of design information decision than with economics, does one ascribe blame to an individual entity linked to an error.