You might remember me blogging about the Indianapolis incident where three babies died after being mistakenly  given an adult dose of heparin back in 2007. The same set of failure modes led to a non-fatal overdose of actor Dennis Quaid’s twin babies. These episodes teach us a lot about failure modes in healthcare (it’s often multiple things that go wrong in succession) and the management response to these problems. It seems that hospital leaders often … Continue reading Let’s Sign Documents Promising Not to Make Errors?