Comment by mncharity

And in addition to variance among institutions, there variance in practice at each. The best groups have a consummate professional's focus on reducing their own. But even at another "one of the best", let alone at the merely good... my impression was "there's lots of holes in the cheese around here", and left me wondering whether/how a transient outsider might usefully help folks towards more of a safety culture. It seems a reoccurring opportunity.