It could have happened to anybody

My rule of thumb is that when an error is made and you can say, "It could have happened to anybody," there is a systems problem behind the error.  Here's a story that demonstrates this so clearly, courtesy of our friends at MedStar Health.

As you watch the video, imagine the more common scenario in hospitals, where the clinician is blamed and where the underlying problem goes unsolved.

Thanks to Annie for sharing her story!