Over the course of these two days, we have had the opportunity to watch and discuss the stories of Lewis Blackman and Michael Skolnik. Unfortunately, while both patients had the worst outcomes imaginable due to negligence, both patients suffered their plight due to different system processes that were in place. There was no one person at fault for either of these outcomes, but rather a system that failed to serve its purpose. And this system still continues to fail its patients on a daily basis. John Nance’s talk today was right on the money by saying that we as physicians need to be the leaders of this system change not commanders. We need to move away from this culture of individualizing the mistakes and focus on collaborative environment. People will make errors, which will lead to accidents; and accidents, especially in our line of work, can sometimes lead to death. Even if we change the people involved, mistakes will continue to happen, if there is no change in the system. And changing a system is no easy task.
