Imagine you are in an airport anxiously awaiting the boarding call for your flight with thinning patience and increasing anxiety. Suddenly, you are alerted to a monitor where your flight status has changed from “On Time” to “Delayed” and later from “Delayed” to “Canceled.” You begin to wonder about the specific concatenation of events that led to your flight’s cancellation. How many people in how many different states contributed to the cancellation? Was it a mechanical issue? Inclement weather? Air traffic control error? You realize all of the interlocking pieces that are at work in getting an airplane to a certain destination and find solace in the fact that you will never truly know what went wrong.
Now imagine you’re in a hospital waiting room anxiously awaiting the surgical results of a loved one. Behind the closed doors of the surgical suite it seems equally impossible to know all of the people who were involved in the consultations and care of your loved one. If the news proves to be poor, how can you figure out all of the people who contributed in causing the inappropriate result? Are you left to rely solely on the medical records authored by the potential culprit (or culprits) and hope that everyone responsible is included? Well, you should not.
