The Action Item Problem#

Post-mortem reviews produce action items. Teams agree on what needs to change. Then weeks pass, priorities shift, and items quietly decay into a backlog nobody checks. The next incident hits the same root cause, and the post-mortem produces the same action items again.

Studies of recurring incidents consistently show the root cause was identified in a previous post-mortem, and the corresponding action item was never completed. Action item tracking is the mechanism by which incidents make systems more reliable instead of just more documented.