Why each patch looks reasonable
When a process fails, the failure is visible: a missed check, an incorrect payment, a task that slips through. The cost of adding a safeguard is less visible at first. A new form may seem like a small price for catching the mistake next time, especially to the person responsible for preventing it.
But the form changes the work for everyone who uses it. If it introduces delay or confusion, people find ways around it. That workaround can create a fresh risk, prompting another person to add a review or approval. Each response addresses the problem most obvious to its author, while the added steps' combined burden belongs to no one in particular.
How patches become a maze
This is a form of local problem-solving: people improve the part of a system they can see, without necessarily seeing how their fix affects the whole. Responsibility is often divided, too. One person owns the original error, another owns the new control, and someone else has to make the process move again.
The result can be a feedback loop. More rules make the process harder to follow; difficulty encourages workarounds; workarounds make outcomes less predictable; and unpredictability seems to call for still more rules. Because each layer was added in response to a real concern, removing one can feel riskier than keeping it—even if the layers together now cause delays or confusion.
The practical consequence is that a process can grow more elaborate without becoming more reliable. Sometimes the most revealing question is not “What safeguard should we add?” but “Which earlier step is creating the problem this safeguard is meant to contain?”
