For the external points in the sequence there must be systems analysis and redesign of elements of the system and the system as a whole. A medication container would tell the person holding it what its name is, what the appropriate dose is, how it should be used, and what the consequences will be if it is used in any of a variety of improper ways. And it would say all this in multiple ways, clearly and unambiguously, as if on the assumption that the person holding it was blind, stupid, and ignorant. It is an unfortunate fact that the whole process, from the writing of a prescription to the preparation of the dose to the administration of the medication, is shot full of problems stemming from appalling handwriting and ambiguous abbreviations, poorly designed packaging and non-standard labeling. Blame implies a theory that incipient errors can be perceived by the actor before they are executed, and voluntarily controlled to prevent their execution.
Responsibility implies a theory that consequences arise because of flaws in behavior.
Finally, one must accept the fact that various errors will occur and try to prevent or inhibit the translation of the error into an accident. The Food and Drug Administration and the manufacturers must stop expecting nurses and physicians to use things correctly every time. Each medication package and each medical device must be subjected to Failure Mode Analysis. This means that the possible ways in which each package or device can be misused should be exhaustively tabulated. Then the outcomes of each misuse are identified and evaluated.