“If you can’t analyze what went wrong without such analysis being criticized as “blame”,”
Unfortunately this is NOT the case — the CDC is making the UNSUBSTANTIATED statement that the nurse breached protocol, without any evidence of whether or not she did and without them being able to say what the breach was.
If she was following prescribed protocols to the letter, then she could not have gotten Ebola. So it is pretty clear that either the PPE was breached (which she would have noticed) or she was *not* following standard protocols as described by CDC and others. It could be that the hospital did not properly teach her--in that case, she would not have been using proper procedure, but a portion of blame would fall on the hospital.
As someone mentioned earlier in the thread, the descriptions of her PPE indicates that she was wearing level 2 PPE, not level 4. That is a breach of standard protocol.
Understanding what went wrong is crucial to preventing similar incidents in the future. Accident analysis is not done to "blame the victim"--rather, it is a crucial component of accident avoidance. People who work in safety and risk management do these analyses all the time. There are whole websites devoted to them.