Author: Suzanne Gordon
Publisher: Cornell University Press
ISBN: 0801465788
Category : Medical
Languages : en
Pages : 279
Book Description
The U.S. healthcare system is now spending many millions of dollars to improve "patient safety" and "inter-professional practice." Nevertheless, an estimated 100,000 patients still succumb to preventable medical errors or infections every year. How can health care providers reduce the terrible financial and human toll of medical errors and injuries that harm rather than heal? Beyond the Checklist argues that lives could be saved and patient care enhanced by adapting the relevant lessons of aviation safety and teamwork. In response to a series of human-error caused crashes, the airline industry developed the system of job training and information sharing known as Crew Resource Management (CRM). Under the new industry-wide system of CRM, pilots, flight attendants, and ground crews now communicate and cooperate in ways that have greatly reduced the hazards of commercial air travel. The coauthors of this book sought out the aviation professionals who made this transformation possible. Beyond the Checklist gives us an inside look at CRM training and shows how airline staff interaction that once suffered from the same dysfunction that too often undermines real teamwork in health care today has dramatically improved. Drawing on the experience of doctors, nurses, medical educators, and administrators, this book demonstrates how CRM can be adapted, more widely and effectively, to health care delivery. The authors provide case studies of three institutions that have successfully incorporated CRM-like principles into the fabric of their clinical culture by embracing practices that promote common patient safety knowledge and skills.They infuse this study with their own diverse experience and collaborative spirit: Patrick Mendenhall is a commercial airline pilot who teaches CRM; Suzanne Gordon is a nationally known health care journalist, training consultant, and speaker on issues related to nursing; and Bonnie Blair O'Connor is an ethnographer and medical educator who has spent more than two decades observing medical training and teamwork from the inside.
Beyond the Checklist
Author: Suzanne Gordon
Publisher: Cornell University Press
ISBN: 0801465788
Category : Medical
Languages : en
Pages : 279
Book Description
The U.S. healthcare system is now spending many millions of dollars to improve "patient safety" and "inter-professional practice." Nevertheless, an estimated 100,000 patients still succumb to preventable medical errors or infections every year. How can health care providers reduce the terrible financial and human toll of medical errors and injuries that harm rather than heal? Beyond the Checklist argues that lives could be saved and patient care enhanced by adapting the relevant lessons of aviation safety and teamwork. In response to a series of human-error caused crashes, the airline industry developed the system of job training and information sharing known as Crew Resource Management (CRM). Under the new industry-wide system of CRM, pilots, flight attendants, and ground crews now communicate and cooperate in ways that have greatly reduced the hazards of commercial air travel. The coauthors of this book sought out the aviation professionals who made this transformation possible. Beyond the Checklist gives us an inside look at CRM training and shows how airline staff interaction that once suffered from the same dysfunction that too often undermines real teamwork in health care today has dramatically improved. Drawing on the experience of doctors, nurses, medical educators, and administrators, this book demonstrates how CRM can be adapted, more widely and effectively, to health care delivery. The authors provide case studies of three institutions that have successfully incorporated CRM-like principles into the fabric of their clinical culture by embracing practices that promote common patient safety knowledge and skills.They infuse this study with their own diverse experience and collaborative spirit: Patrick Mendenhall is a commercial airline pilot who teaches CRM; Suzanne Gordon is a nationally known health care journalist, training consultant, and speaker on issues related to nursing; and Bonnie Blair O'Connor is an ethnographer and medical educator who has spent more than two decades observing medical training and teamwork from the inside.
Publisher: Cornell University Press
ISBN: 0801465788
Category : Medical
Languages : en
Pages : 279
Book Description
The U.S. healthcare system is now spending many millions of dollars to improve "patient safety" and "inter-professional practice." Nevertheless, an estimated 100,000 patients still succumb to preventable medical errors or infections every year. How can health care providers reduce the terrible financial and human toll of medical errors and injuries that harm rather than heal? Beyond the Checklist argues that lives could be saved and patient care enhanced by adapting the relevant lessons of aviation safety and teamwork. In response to a series of human-error caused crashes, the airline industry developed the system of job training and information sharing known as Crew Resource Management (CRM). Under the new industry-wide system of CRM, pilots, flight attendants, and ground crews now communicate and cooperate in ways that have greatly reduced the hazards of commercial air travel. The coauthors of this book sought out the aviation professionals who made this transformation possible. Beyond the Checklist gives us an inside look at CRM training and shows how airline staff interaction that once suffered from the same dysfunction that too often undermines real teamwork in health care today has dramatically improved. Drawing on the experience of doctors, nurses, medical educators, and administrators, this book demonstrates how CRM can be adapted, more widely and effectively, to health care delivery. The authors provide case studies of three institutions that have successfully incorporated CRM-like principles into the fabric of their clinical culture by embracing practices that promote common patient safety knowledge and skills.They infuse this study with their own diverse experience and collaborative spirit: Patrick Mendenhall is a commercial airline pilot who teaches CRM; Suzanne Gordon is a nationally known health care journalist, training consultant, and speaker on issues related to nursing; and Bonnie Blair O'Connor is an ethnographer and medical educator who has spent more than two decades observing medical training and teamwork from the inside.
Beyond the Checklist
Author: Suzanne Gordon
Publisher: Cornell University Press
ISBN: 0801465346
Category : Medical
Languages : en
Pages : 279
Book Description
The U.S. healthcare system is now spending many millions of dollars to improve "patient safety" and "inter-professional practice." Nevertheless, an estimated 100,000 patients still succumb to preventable medical errors or infections every year. How can health care providers reduce the terrible financial and human toll of medical errors and injuries that harm rather than heal? Beyond the Checklist argues that lives could be saved and patient care enhanced by adapting the relevant lessons of aviation safety and teamwork. In response to a series of human-error caused crashes, the airline industry developed the system of job training and information sharing known as Crew Resource Management (CRM). Under the new industry-wide system of CRM, pilots, flight attendants, and ground crews now communicate and cooperate in ways that have greatly reduced the hazards of commercial air travel. The coauthors of this book sought out the aviation professionals who made this transformation possible. Beyond the Checklist gives us an inside look at CRM training and shows how airline staff interaction that once suffered from the same dysfunction that too often undermines real teamwork in health care today has dramatically improved. Drawing on the experience of doctors, nurses, medical educators, and administrators, this book demonstrates how CRM can be adapted, more widely and effectively, to health care delivery. The authors provide case studies of three institutions that have successfully incorporated CRM-like principles into the fabric of their clinical culture by embracing practices that promote common patient safety knowledge and skills.They infuse this study with their own diverse experience and collaborative spirit: Patrick Mendenhall is a commercial airline pilot who teaches CRM; Suzanne Gordon is a nationally known health care journalist, training consultant, and speaker on issues related to nursing; and Bonnie Blair O'Connor is an ethnographer and medical educator who has spent more than two decades observing medical training and teamwork from the inside.
Publisher: Cornell University Press
ISBN: 0801465346
Category : Medical
Languages : en
Pages : 279
Book Description
The U.S. healthcare system is now spending many millions of dollars to improve "patient safety" and "inter-professional practice." Nevertheless, an estimated 100,000 patients still succumb to preventable medical errors or infections every year. How can health care providers reduce the terrible financial and human toll of medical errors and injuries that harm rather than heal? Beyond the Checklist argues that lives could be saved and patient care enhanced by adapting the relevant lessons of aviation safety and teamwork. In response to a series of human-error caused crashes, the airline industry developed the system of job training and information sharing known as Crew Resource Management (CRM). Under the new industry-wide system of CRM, pilots, flight attendants, and ground crews now communicate and cooperate in ways that have greatly reduced the hazards of commercial air travel. The coauthors of this book sought out the aviation professionals who made this transformation possible. Beyond the Checklist gives us an inside look at CRM training and shows how airline staff interaction that once suffered from the same dysfunction that too often undermines real teamwork in health care today has dramatically improved. Drawing on the experience of doctors, nurses, medical educators, and administrators, this book demonstrates how CRM can be adapted, more widely and effectively, to health care delivery. The authors provide case studies of three institutions that have successfully incorporated CRM-like principles into the fabric of their clinical culture by embracing practices that promote common patient safety knowledge and skills.They infuse this study with their own diverse experience and collaborative spirit: Patrick Mendenhall is a commercial airline pilot who teaches CRM; Suzanne Gordon is a nationally known health care journalist, training consultant, and speaker on issues related to nursing; and Bonnie Blair O'Connor is an ethnographer and medical educator who has spent more than two decades observing medical training and teamwork from the inside.
The Checklist Manifesto
Author: Atul Gawande
Publisher: Metropolitan Books
ISBN: 1429953381
Category : Medical
Languages : en
Pages : 225
Book Description
The New York Times bestselling author of Being Mortal and Complications reveals the surprising power of the ordinary checklist We live in a world of great and increasing complexity, where even the most expert professionals struggle to master the tasks they face. Longer training, ever more advanced technologies—neither seems to prevent grievous errors. But in a hopeful turn, acclaimed surgeon and writer Atul Gawande finds a remedy in the humblest and simplest of techniques: the checklist. First introduced decades ago by the U.S. Air Force, checklists have enabled pilots to fly aircraft of mind-boggling sophistication. Now innovative checklists are being adopted in hospitals around the world, helping doctors and nurses respond to everything from flu epidemics to avalanches. Even in the immensely complex world of surgery, a simple ninety-second variant has cut the rate of fatalities by more than a third. In riveting stories, Gawande takes us from Austria, where an emergency checklist saved a drowning victim who had spent half an hour underwater, to Michigan, where a cleanliness checklist in intensive care units virtually eliminated a type of deadly hospital infection. He explains how checklists actually work to prompt striking and immediate improvements. And he follows the checklist revolution into fields well beyond medicine, from disaster response to investment banking, skyscraper construction, and businesses of all kinds. An intellectual adventure in which lives are lost and saved and one simple idea makes a tremendous difference, The Checklist Manifesto is essential reading for anyone working to get things right.
Publisher: Metropolitan Books
ISBN: 1429953381
Category : Medical
Languages : en
Pages : 225
Book Description
The New York Times bestselling author of Being Mortal and Complications reveals the surprising power of the ordinary checklist We live in a world of great and increasing complexity, where even the most expert professionals struggle to master the tasks they face. Longer training, ever more advanced technologies—neither seems to prevent grievous errors. But in a hopeful turn, acclaimed surgeon and writer Atul Gawande finds a remedy in the humblest and simplest of techniques: the checklist. First introduced decades ago by the U.S. Air Force, checklists have enabled pilots to fly aircraft of mind-boggling sophistication. Now innovative checklists are being adopted in hospitals around the world, helping doctors and nurses respond to everything from flu epidemics to avalanches. Even in the immensely complex world of surgery, a simple ninety-second variant has cut the rate of fatalities by more than a third. In riveting stories, Gawande takes us from Austria, where an emergency checklist saved a drowning victim who had spent half an hour underwater, to Michigan, where a cleanliness checklist in intensive care units virtually eliminated a type of deadly hospital infection. He explains how checklists actually work to prompt striking and immediate improvements. And he follows the checklist revolution into fields well beyond medicine, from disaster response to investment banking, skyscraper construction, and businesses of all kinds. An intellectual adventure in which lives are lost and saved and one simple idea makes a tremendous difference, The Checklist Manifesto is essential reading for anyone working to get things right.
Beyond the Bake Sale
Author: Anne T. Henderson
Publisher: ReadHowYouWant.com
ISBN: 1458781135
Category : Education
Languages : en
Pages : 522
Book Description
Countless studies demonstrate that students with parents actively involved in their education at home and school are more likely to earn higher grades and test scores, enroll in higher-level programs, graduate from high school, and go on to post-secondary education. Beyond the Bake Sale shows how to form these essential partnerships and how to make them work. Packed with tips from principals and teachers, checklists, and an invaluable resource section, Beyond the Bake Sale reveals how to build strong collaborative relationships and offers practical advice for improving interactions between parents and teachers, from insuring that PTA groups are constructive and inclusive to navigating the complex issues surrounding diversity in the classroom. Written with candor, clarity, and humor, Beyond the Bake Sale is essential reading for teachers, parents on the front lines in public schools, and administrators and policy makers at all levels.
Publisher: ReadHowYouWant.com
ISBN: 1458781135
Category : Education
Languages : en
Pages : 522
Book Description
Countless studies demonstrate that students with parents actively involved in their education at home and school are more likely to earn higher grades and test scores, enroll in higher-level programs, graduate from high school, and go on to post-secondary education. Beyond the Bake Sale shows how to form these essential partnerships and how to make them work. Packed with tips from principals and teachers, checklists, and an invaluable resource section, Beyond the Bake Sale reveals how to build strong collaborative relationships and offers practical advice for improving interactions between parents and teachers, from insuring that PTA groups are constructive and inclusive to navigating the complex issues surrounding diversity in the classroom. Written with candor, clarity, and humor, Beyond the Bake Sale is essential reading for teachers, parents on the front lines in public schools, and administrators and policy makers at all levels.
Lydia Bailey
Author: Karen Nipps
Publisher: Penn State Press
ISBN: 0271055715
Category : Language Arts & Disciplines
Languages : en
Pages : 327
Book Description
"Explores the life and work of Lydia Bailey, a leading printer in the book trade in Philadelphia from 1808 to 1861. Includes a list of almost nine hundred of her known imprints"--Provided by publisher.
Publisher: Penn State Press
ISBN: 0271055715
Category : Language Arts & Disciplines
Languages : en
Pages : 327
Book Description
"Explores the life and work of Lydia Bailey, a leading printer in the book trade in Philadelphia from 1808 to 1861. Includes a list of almost nine hundred of her known imprints"--Provided by publisher.
The Sales Checklist(TM)
Author: David L Varner
Publisher:
ISBN:
Category :
Languages : en
Pages : 136
Book Description
The Sales Checklist(TM) - Get it right every timeAn innovative, easy to use checklist to avoid missing critical steps and minimize losses in complex sales.The Sales Checklist(TM) empowers sales professionals to immediately have a higher baseline of performance by reminding them of the necessary steps in a sales process where missing one step potentially has the same consequences as missing all the steps.Checklists minimize avoidable failures due to lack of attention, memory, or thoroughness.In today's complex selling environment, knowing how to ask questions, develop trigger events, make presentations, handle objections, etc. is not enough. Knowing what to do, and not missing steps, is just as critical.Pilots know how to fly airplanes, but they use a checklist to make certain they don't miss a step; they need to get it right every time. It's the same with salespeople, to get it right every time, they need to use The Sales Checklist(TM).The Sales Checklist(TM) is easy to use, simple to coach, and produces immediate results.
Publisher:
ISBN:
Category :
Languages : en
Pages : 136
Book Description
The Sales Checklist(TM) - Get it right every timeAn innovative, easy to use checklist to avoid missing critical steps and minimize losses in complex sales.The Sales Checklist(TM) empowers sales professionals to immediately have a higher baseline of performance by reminding them of the necessary steps in a sales process where missing one step potentially has the same consequences as missing all the steps.Checklists minimize avoidable failures due to lack of attention, memory, or thoroughness.In today's complex selling environment, knowing how to ask questions, develop trigger events, make presentations, handle objections, etc. is not enough. Knowing what to do, and not missing steps, is just as critical.Pilots know how to fly airplanes, but they use a checklist to make certain they don't miss a step; they need to get it right every time. It's the same with salespeople, to get it right every time, they need to use The Sales Checklist(TM).The Sales Checklist(TM) is easy to use, simple to coach, and produces immediate results.
A Checklist for Murder
Author: Anthony Flacco
Publisher: Diversion Publishing Corp.
ISBN: 1626819025
Category : True Crime
Languages : en
Pages : 427
Book Description
As seen on Investigation Discovery: the story of killer husband and father Robert Peernock from the New York Times–bestselling author of Impossible Odds. Robert Peernock appeared to have the ideal life. Working as a pyrotechnics engineer and computer expert and coming home to his wife and daughter, Peernock projected the American dream. Even when he and his wife separated, it seemed amicable, just a small bump for the well-to-do family. But there was madness in his house: In private, Peernock was violent, subtly manipulative, and bordering on psychotic. But the horrifying details of his home life would only come to light after Peernock finally lost all control. Peernock had come home, brutally beat both his wife and daughter, force fed them alcohol, and deliberately sent them to their death behind the wheel, staging it to look like a drunk driving accident. He didn’t foresee that his daughter would survive, and even with years of abuse, her attempted murder, and horrendous injuries, he never anticipated that she would speak so powerfully against him. Throughout his trial, Peernock claimed a massive government conspiracy against him. He hired and fired lawyers multiple times, deadlocking juries and spinning a web of lies. New York Times–bestselling author Anthony Flacco chronicles the sensational trial and all the terror that preceded it, looking deep into the mind of a deranged killer whose American dream was a waking nightmare for those trapped within it.
Publisher: Diversion Publishing Corp.
ISBN: 1626819025
Category : True Crime
Languages : en
Pages : 427
Book Description
As seen on Investigation Discovery: the story of killer husband and father Robert Peernock from the New York Times–bestselling author of Impossible Odds. Robert Peernock appeared to have the ideal life. Working as a pyrotechnics engineer and computer expert and coming home to his wife and daughter, Peernock projected the American dream. Even when he and his wife separated, it seemed amicable, just a small bump for the well-to-do family. But there was madness in his house: In private, Peernock was violent, subtly manipulative, and bordering on psychotic. But the horrifying details of his home life would only come to light after Peernock finally lost all control. Peernock had come home, brutally beat both his wife and daughter, force fed them alcohol, and deliberately sent them to their death behind the wheel, staging it to look like a drunk driving accident. He didn’t foresee that his daughter would survive, and even with years of abuse, her attempted murder, and horrendous injuries, he never anticipated that she would speak so powerfully against him. Throughout his trial, Peernock claimed a massive government conspiracy against him. He hired and fired lawyers multiple times, deadlocking juries and spinning a web of lies. New York Times–bestselling author Anthony Flacco chronicles the sensational trial and all the terror that preceded it, looking deep into the mind of a deranged killer whose American dream was a waking nightmare for those trapped within it.
The Job Search Checklist
Author: Damian Birkel
Publisher: AMACOM
ISBN: 0814432921
Category : Self-Help
Languages : en
Pages : 290
Book Description
It’s been a long time since you had to search for a new job. You may be wondering, How did I get this last one so many years ago? What has changed since I last hit the job market? Have I since gathered more knowledge and experience that qualifies me for something better this time around? Where does one get started? The Job Search Checklist is your saving grace! This indispensable guide covers everything from dealing with the emotional impact of being laid off to rebuilding your professional identity. Within these pages, you’ll find solid advice on: • Developing a career plan by taking stock of your experience, abilities, and goals • Crafting an effective résumé and building Internet-friendly documents • Creating a “personal marketing plan” to promote yourself to potential employers • Finding the hidden job market through in-person and online networking• And much more!Complete with downloadable templates, sample cover letters, a range of effective résumé formats, and helpful checklists throughout the book, this invaluable resource gets you on the right path toward your next career and keeps you there.
Publisher: AMACOM
ISBN: 0814432921
Category : Self-Help
Languages : en
Pages : 290
Book Description
It’s been a long time since you had to search for a new job. You may be wondering, How did I get this last one so many years ago? What has changed since I last hit the job market? Have I since gathered more knowledge and experience that qualifies me for something better this time around? Where does one get started? The Job Search Checklist is your saving grace! This indispensable guide covers everything from dealing with the emotional impact of being laid off to rebuilding your professional identity. Within these pages, you’ll find solid advice on: • Developing a career plan by taking stock of your experience, abilities, and goals • Crafting an effective résumé and building Internet-friendly documents • Creating a “personal marketing plan” to promote yourself to potential employers • Finding the hidden job market through in-person and online networking• And much more!Complete with downloadable templates, sample cover letters, a range of effective résumé formats, and helpful checklists throughout the book, this invaluable resource gets you on the right path toward your next career and keeps you there.
From Silence to Voice
Author: Bernice Buresh
Publisher: Ilr Press
ISBN: 9780801488689
Category : Medical
Languages : en
Pages : 294
Book Description
As nurses face the ongoing challenges of an increasing need for their services combined with economic pressures, members of the largest profession in health care must become more visible, vocal, and influential. The first communication guidebook designed expressly for nurses, From Silence to Voice helps nurses understand and overcome the self-silencing that often leads RNs to downplay their own expertise and their contributions to the care of the sick and the health of the public. Bernice Buresh and Suzanne Gordon teach nurses, nurse educators, and nurse researchers critical skills they can use to explain their work to other health-care professionals, journalists, policymakers, and political representatives. From Silence to Voice features stories about nurses who ensure that patients receive appropriate, timely, and even life-saving care, nurses who make all the difference while crises are underway but whose contributions are neglected in medical charts and thank-you notes, nurses who are left out altogether or obscured by the generic "nurse." However, the book also provides detailed accounts of nurses who do make their voices heard, who do make their concerns public-- and it shows how those successes can be duplicated. Buresh and Gordon draw on real-world examples that will help nurses to - gain respect for themselves as professionals, - communicate well with both patients and health-care colleagues, - understand how the news media work, - collaborate with public relations professionals, - write effective letters to the editor and publish op-ed pieces, - appear on television and radio, and - promote research on nursing.
Publisher: Ilr Press
ISBN: 9780801488689
Category : Medical
Languages : en
Pages : 294
Book Description
As nurses face the ongoing challenges of an increasing need for their services combined with economic pressures, members of the largest profession in health care must become more visible, vocal, and influential. The first communication guidebook designed expressly for nurses, From Silence to Voice helps nurses understand and overcome the self-silencing that often leads RNs to downplay their own expertise and their contributions to the care of the sick and the health of the public. Bernice Buresh and Suzanne Gordon teach nurses, nurse educators, and nurse researchers critical skills they can use to explain their work to other health-care professionals, journalists, policymakers, and political representatives. From Silence to Voice features stories about nurses who ensure that patients receive appropriate, timely, and even life-saving care, nurses who make all the difference while crises are underway but whose contributions are neglected in medical charts and thank-you notes, nurses who are left out altogether or obscured by the generic "nurse." However, the book also provides detailed accounts of nurses who do make their voices heard, who do make their concerns public-- and it shows how those successes can be duplicated. Buresh and Gordon draw on real-world examples that will help nurses to - gain respect for themselves as professionals, - communicate well with both patients and health-care colleagues, - understand how the news media work, - collaborate with public relations professionals, - write effective letters to the editor and publish op-ed pieces, - appear on television and radio, and - promote research on nursing.
When We Do Harm
Author: Danielle Ofri, MD
Publisher: Beacon Press
ISBN: 0807037885
Category : Medical
Languages : en
Pages : 274
Book Description
Medical mistakes are more pervasive than we think. How can we improve outcomes? An acclaimed MD’s rich stories and research explore patient safety. Patients enter the medical system with faith that they will receive the best care possible, so when things go wrong, it’s a profound and painful breach. Medical science has made enormous strides in decreasing mortality and suffering, but there’s no doubt that treatment can also cause harm, a significant portion of which is preventable. In When We Do Harm, practicing physician and acclaimed author Danielle Ofri places the issues of medical error and patient safety front and center in our national healthcare conversation. Drawing on current research, professional experience, and extensive interviews with nurses, physicians, administrators, researchers, patients, and families, Dr. Ofri explores the diagnostic, systemic, and cognitive causes of medical error. She advocates for strategic use of concrete safety interventions such as checklists and improvements to the electronic medical record, but focuses on the full-scale cultural and cognitive shifts required to make a meaningful dent in medical error. Woven throughout the book are the powerfully human stories that Dr. Ofri is renowned for. The errors she dissects range from the hardly noticeable missteps to the harrowing medical cataclysms. While our healthcare system is—and always will be—imperfect, Dr. Ofri argues that it is possible to minimize preventable harms, and that this should be the galvanizing issue of current medical discourse.
Publisher: Beacon Press
ISBN: 0807037885
Category : Medical
Languages : en
Pages : 274
Book Description
Medical mistakes are more pervasive than we think. How can we improve outcomes? An acclaimed MD’s rich stories and research explore patient safety. Patients enter the medical system with faith that they will receive the best care possible, so when things go wrong, it’s a profound and painful breach. Medical science has made enormous strides in decreasing mortality and suffering, but there’s no doubt that treatment can also cause harm, a significant portion of which is preventable. In When We Do Harm, practicing physician and acclaimed author Danielle Ofri places the issues of medical error and patient safety front and center in our national healthcare conversation. Drawing on current research, professional experience, and extensive interviews with nurses, physicians, administrators, researchers, patients, and families, Dr. Ofri explores the diagnostic, systemic, and cognitive causes of medical error. She advocates for strategic use of concrete safety interventions such as checklists and improvements to the electronic medical record, but focuses on the full-scale cultural and cognitive shifts required to make a meaningful dent in medical error. Woven throughout the book are the powerfully human stories that Dr. Ofri is renowned for. The errors she dissects range from the hardly noticeable missteps to the harrowing medical cataclysms. While our healthcare system is—and always will be—imperfect, Dr. Ofri argues that it is possible to minimize preventable harms, and that this should be the galvanizing issue of current medical discourse.