To err is human, but it is also wise to do our best to prevent the same mistake from occurring a second time. These authors describe how morbidity and mortality conferences can be used to substantially improve the quality of care patients receive, patients’ outcomes, satisfaction among staff members, and most importantly, patients’ safety.

An 80-year-old woman who intentionally overdosed at home on propranolol hydrochloride (Inderal) and tricyclic antidepressants was brought to the emergency department via ambulance. Upon her arrival, she was immediately intubated, treated for her overdose per protocol, and admitted to the intensive care unit (ICU). Her hospitalization was notable for development of an infiltrate in the lower lobe of the left lung on day 2 after extubation. She was able to follow simple commands but had frequent episodes of agitation and decreased mentation. Her speech was...

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