both holding policy- makers individually responsible for ‘‘creating and maintaining the conditions for proper institutional oversight’’ and holding overseers individually responsible for fulfilling their duties of vigilance. This study analyzes both the prospective and retrospective oversight ethics of business licensing in Israel. In order to capture retrospective actions of investigation and improvement of oversight design problems, we chose four focusing events which could be reasonably expected to lead to oversight institutional change. We use Birkland’s definition of a ‘‘focusing event’’: ‘‘an event that is sudden; rela- tively uncommon; can be reasonably defined as harmful or revealing the possibility of potentially greater future harms; has harms that are concentrated