This is similar to the approach in healthcare, at least my experience in pharmacy.

When an error occurs we find the root cause but in 99% of cases a change to the environment/process is required to avoid it in the future.

Humans are all imperfect, their competence will change hour to hour let alone day to day. But you can control a system and put checks in place (admittedly a human can still do the process wrong, but then you need to think how the process can be clearer).

No-blame culture is very effective at providing an open environment to share mistakes, learn, but most importantly avoid reoccurance.