What are some effective case studies of post-mortems?

What are some effective case studies of post-mortems?

Post-mortems are critical for learning from failures. One effective case study is the 2012 Knight Capital Group incident, where a software glitch caused a $440 million loss in just 45 minutes. The post-mortem revealed flaws in their deployment process and led to significant changes in their risk management.

What changes did they implement after the post-mortem?

They improved their software deployment processes, implemented better testing protocols, and enhanced their risk management strategies to prevent similar issues in the future.

Can you give another example from a different industry?

Sure! In healthcare, the 2014 case of a hospital's medication error led to a post-mortem that identified communication breakdowns. They implemented a new electronic health record system and standardized medication protocols to enhance patient safety.

What are the key components of a successful post-mortem?

Key components include a clear agenda, open communication, a focus on facts rather than blame, actionable insights, and follow-up on the implementation of changes.