With the leisure of hindsight, it is easy to tear apart case reports, and identify the single most glaring mistake that is simply responsible for the poor outcome. However, one undeniable truth in safety culture and human error is that “try harder” or “don’t make mistakes” or “be more vigilant” are ineffective safeguards and ring hollow. Here, I had the opportunity to join with physicians in analyzing a case that might be (like any other mistake) dismissed as poor judgment, lack of knowledge, or some other simple explanation, and instead we dig deep into the factors that confused a highly skilled and well intentioned team. The lessons contained herein are broadly applicable; we can all can take these lessons forward to improve their own medical decisions in other contexts.

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