“Brilliant” is the only word to describe Elizabeth Henneman’s article in the October issue of Critical Care Nurse entitled “Unreported Errors in the Intensive Care Unit” (October 2007:27–34). And the brilliance showed in so many ways. From identifying the 8 errors that occurred with her own patients during a single shift, to delineating the types of errors involved and her insightful discussion of how we all fail to recognize chronic systems problems as contributors to error, Henneman has broken new ground in the conversation about safety in nursing and healthcare. This article is a valuable contribution to the growing body of literature on safety and harm—and certainly it is the most unique and practical one that I have read.

Besides the attributes of the article already mentioned, by far the most powerful feature is the author’s willingness to share...

You do not currently have access to this content.