Police make mistakes.

Most are minor and the universe unfolds without notice.

But when a cop shoots and kills a civilian, the world stops. The recent shooting of a Toronto man on an an abandoned streetcar appears, in hindsight at least, to be a mistake.

The man was holding a relatively small knife. He was alone on the streetcar. He held no hostages. Why not use time, distance and negotiation to calm the situation?

Or, if police feared he’d run and endanger passersby, why not use a Taser or some other form of non-lethal force?

Unfortunately, the case is not isolated. A number of Canadian incidents in recent years involved police using lethal force against civilians suffering some kind of crisis in their mental illness.

I am a director on the Lieutenant Governor’s Circle on Mental Health and Addiction. The Circle’s aim is to increase understanding and reduce stigma surrounding mental illness and addiction.

So part of me is shocked that Toronto police didn’t handle the young man on the streetcar with a more subtle and humane approach.

Yet recent work I’ve done with the Canadian Patient Safety Institute taught me to look at these situations in a new light. Rarely are medical errors caused by individuals. Rarely is a single doctor or nurse the cause of patient harm.

Yet we assume so. Perhaps it is human nature to look for simple answers and a scapegoat.

Yet the patient safety community has matured beyond “shame and blame.” The causes of medical errors are typically systemic.

For example, two similar-sounding, but profoundly different drugs stored next to each other in a cabinet is an accident waiting to happen.

But most medical errors reveal a failure of systems, be they procedures, communications or even training.

The latter, training, seems particularly important in regard to police encounters with mental health patients in crisis.

The Edmonton Police Service, fortunately, has already started training its officers in dealing with mentally ill people.

A local CBC piece on the training program can be found here.

Candidates in a civic election commonly find things to criticize. And yes, there are a number of issues I have with policing in Edmonton, today.

But this training program, under the supervision of the U of A’s Dr. Peter Silverstone, is something to applaud.

Credit the Edmonton Police Service for establishing a training program worthy of coverage by one of the world’s leading newspapers, The Guardian. You can read that piece here.