This question was asked in an interest group that I belong to on LinkedIn. The questioner asked: How do you go about correcting this, other than discipline or firing?
Now, if you are the manufacturer of a medical device (hardware or software) and a patient or operator is killed or injured because of a "reasonably foreseeable usage error", then the manufacturer of the medical device is held responsible by government regulators for not building into the design of the medical device a means of preventing that usage error. The reasoning is that operator (usage) error (other than wilful and malicious) should be preventable and, as such, treated as an effect, not a cause.
Non-volitional usage errors fall into 3 categories:
SLIPS are, typically, inadvertent finger problems such as accidentally punching a wrong number;
LAPSES are 'missed' actions typically due to forgetfulness or a lapse in attention;
MISTAKES happen when the operator does an action believing it to be the correct one but it produces an undesired outcome.
These point to 3 different types of root cause. Each should be able to be addressed in an appropriate and effective way. What applies to the operation of a medical device (or passenger airliner) can and should also be applied to the operator process in a manufacturing plant, or a Personal Support Worker providing a service in a long-term care home.