all human beings err, but they err frequently and in predictable, patterned ways. - Atul Gawande

No matter what measures are taken, doctors will sometimes falter, and it isn't reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it.

The investigators at Johns Hopkins and elsewhere had also observed that when nurses were given a chance to say their names and mention concerns at the beginning of a case, they were more likely to note problems and offer solutions. The researchers called it an “activation phenomenon.” Giving people a chance to say something at the start seemed to activate their sense of participation and responsibility and their willingness to speak up.

It is a reality of medicine that choosing to not do something — to not order a test, to not give an antibiotic, to not take a patient to the operating room — is far harder than choosing to do it.