From Etsy’s Code as Craft blog, an interesting post about the logic and practice of their non-punitive, blameless post-mortem system for analyzing errors:
Why shouldn’t they be punished or reprimanded? Because an engineer who thinks they’re going to be reprimanded are disincentivized to give the details necessary to get an understanding of the mechanism, pathology, and operation of the failure. This lack of understanding of how the accident occurred all but guarantees that it will repeat. If not with the original engineer, another one in the future.
Although the post itself doesn’t mention the medical system’s “morbidity and mortality” conferences, the related Business Insider article does reference that the healthcare system does something similar to Etsy to enhance patient care. It seems to me that many large organizations could find something like this useful to help overcome the inevitable bureaucratic and communication friction that comes about from having so many more moving parts.