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Dr. Spath did an excellent job of using the error as a springboard to explain the importance of an open and sharing environment of error reporting and learning. Although limited details on the error itself were provided, the information that was contained in the case report does give readers an opportunity to more thoroughly review their own systems to discover if an error such as this can happen in their emergency department (ED).

In Drs. Flanders and Saint’s otherwise superb summary and review of the use of root cause analysis to identify systems’ vulnerabilities and improve overall patient care delivery, I was surprised by their statement that RCAs are “performed by a team with...