A study published in the August issue of the Academy of Management Journal examined how the origin of a failure affects its fix, and it turns out that a problem attributable to one person is less adequately addressed than a problem with wider roots.

“Concentrated failures prompt narrower attributions of responsibility which, whether accurate or not, ultimately lead to less thorough investigations and fewer of the systemwide changes that are typically required to address organizational performance problems,” according to the paper, which was published by Vinit Desai, associate professor of management at the University of Colorado, Denver.

When the same individuals are responsible for multiple failures, organizational leaders have a “well-recognized tendency to merely dismiss culpable parties or make other relatively localized changes.”

Desai reached this conclusion by studying the death rates resulting from cardiac-bypass surgery in more than 115 hospitals in California. The facilities that made the biggest improvements in reducing death rates were those in which the fatalities were dispersed among patients of a number of surgeons, instead of among patients belonging to one or just a few doctors.

At one hospital in particular, half of surgeons lost at least one patient who underwent cardiac-bypass surgery in a two-year period. To cut down on the death rate, the hospital implemented broad procedural changes such as “[putting] evidence-based protocols in place, [providing] educational and skills-based training for staff, and [forming] multidisciplinary committees to identify and resolve quality issues,” Desai said in a release. The next year, a typical number of patients underwent the procedure, but no patients died from it.

Meanwhile, hospitals where patient deaths took place at the hands of a small minority of surgeons didn’t experience a subsequent reduction in cardiac-bypass fatalities, even after the subpar surgeons left those hospitals.

When individuals or specific groups are involved in failures over and over again, decision makers assume the problems will be fixed by firing those responsible for the errors. Such simple changes may be adequate in some cases, the study suggests, but after highly localized failures, leaders also need to address the larger issues as well. Practically speaking, the research encourages managers to avoid “overly simple learning or the pursuit of narrow solutions following localized failures, since the causes of these events may be broader than they appear.”

The overall lesson, Desai says, is to not be too quick to assign blame. Hard as it might be, “deep searches for underlying structural solutions or procedural changes can pay off in a big way even in high-functioning organizations.”