The perfect storm of missteps can lead to terrible outcomes in our hospitals. The more obvious and egregious errors such as wrong-site surgeries and misprescriptions are easy to identify and address (at least in theory). But how do we go about identifying and subsequently correcting the more subtle actions that contribute to poor outcomes, especially those that many of us would hardly view as “mistakes?” Some examples may looking at one’s watch when a patient is talking, forgetting the name of a patient or colleague, and providing false hope when breaking bad news. All of these work against the values of patient-centered care, interprofessional collaboration, and open communication, but are perhaps both the easiest and most difficult to address. However, I am hopeful that over the course of the next few days, we’ll be better equipped to first identify and bring about these necessary changes.
