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• Assess and confront your culture. "If your people can't speak up," he
says, "you're courting disaster."
• Embrace checklists.
• Be ready for the unexpected.
A lot of bad outcomes are scrubbed and sanitized as near-misses
and therapeutic misadventures. "We accept a lot of things as the cost
of doing business," says Dr. Rothfield. "Our culture is not very
accountable." Focus on the first word in the term preventable medical
errors. Our patients don't have to die. That should trump everything
else. OSM
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