Two interesting quotes from the linked paper: > It is very important that after the meeting, the offending employee receive an official, written summary of the

Two interesting quotes from the linked paper: > It is very important that after the meeting, the offending employee receive an official, written summary of the meeting which outlines the next steps in the remediation. The employee should be required to acknowledge that the summary is accurate. Interveners might have to repeat this last step, because the rule offender can find it distressing to acknowledge the meeting’s having taken place > Richard Cook (1998) has pointed out that complex systems such as healthcare are intrinsically hazardous in that they invariably contain changing mixtures of failures, weaknesses, and expertise, and always run in a “degraded” mode. By always running in degraded mode, it's not meant that degraded is the normal state, but that even in a degraded mode everything continues to run. You don't realize the extent of the degradation as long as the gears keep turning.