Run a blameless postmortem that finds the systemic cause instead of the last person to touch it, with a timeline built from evidence and actions that would actually have prevented it.
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npx promptdock@latest install Klickrehan/incident-postmortemStructures a postmortem around the question that actually improves reliability: not 'what broke' but 'why did our system allow this to reach users, and why did it take so long to notice'. Detection time is usually the more damning number, and it is the one most reports skip.
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