A health system that won't learn from its mistakes.

Chandra Keller

Commentary

A health system that won't learn from its mistakes.

September 21, 2022

Keller C. Health Aff (Millwood). 2022;41(9):1353-1356.

View more articles from the same authors.

Communication failures due to hierarchy and silos create opportunities for adverse medication and treatment events. This narrative essay discusses gaps in care coordination that contributed to anticoagulant medication errors. The author outlines areas for improvement such as assignment of accountability for error and commitment to the learning health system as avenues for improvement.

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