I'm looking at it from two ends of vastly different approaches. Yes, safety improvements are necessary and we must continue to strive to make healthcare as safe as humanly possible. I advocate for them in my practice all the time and fortunately for my practice, as long as there is not a true emergency situation, I take my time and not take shortcuts. I'm also fortunate that my environment doesn't interfere with that.
We once admitted a patient from another hospital where a nocturnal intensivist inadvertently placed a central venous catheter to the patient's common carotid artery instead of the internal jugular vein. From his note, it said he used ultrasound guidance. However, he missed an important next step...either the fluid column test or guidewire visualization. He may have visualized the needle enter through the jugular but made the mistake of going through and through that vessel and hitting the artery lying just beneath the vein. Just missing that important next step could have saved him from making the error.
Unfortunately, the safety community is only one part. There is the law enforcement and judicial system that exist alongside as well. They're not always at odds with the safety community but RV's sentinel event is so full of egregious omissions that I can't blame the TBI, subsequent DA charges, the gran jury deliberations, and the upcoming criminal trial from happening.
Oh I'm aware of that. I'm just saying (and I think you agree), that a mistake this monumental is not something easily hidden. However, I am going as far as to not give RV credit for reporting it.