Fifteen-year anniversaries often come and go without fuss, overlooked in favor of those we can mark in full decades. Yet recently, at Johns Hopkins and nationally, we’ve crossed that mark for a couple of events in patient safety that merit both celebration and reflection.

In January 2001, a series of lapses at Johns Hopkins led to the preventable death of Josie King, a toddler recovering from second-degree burns before her condition deteriorated and she developed sepsis. That tragedy, and the June 2001 death of a healthy 24-year-old clinical trial participant, Ellen Roche, brought our organization to a crossroads. Were we going to circle the wagons or take an honest look at ourselves so that we could do bette

This post is from Dr. Peter Pronovost, Senior Vice President for Patient Safety and Quality at Johns Hopkins Medicine and Co-founder of Doctella. This is an excerpt reposted from his blog, Voices for Safer Care. Please visit his website to read the full article.