Okay. Thank you.
I have practised medicine for 25 years. We deal with error. We will look at a critical incident: How did this happen? Was this a huge bungle by one person? Did a number of factors come together to cause this to happen? That is often the case.
One thing we've found in medicine is that we often will have input from other industries that can share with us what they know from their incident analysis and quality improvement. For instance, it's very common practice now for the aviation industry to speak at medical conferences, because they are very good at dissecting critical incidents and coming up with recommendations. Have you used input from other industries that could help give you a better perspective on how to address problems like this and prevent them from happening again?