I was written up for “yelling at staff.” I responded to a code and yelled to the pharmacist to get induction medications, who couldn't hear me over the din of people who had crowded into the room. The report completely failed to contextualize the incident (AMB).

In my role of reviewing patient safety incidents for my anesthesiology department, I investigated a report written by a PACU nurse. A patient in the recovery room had received versed, fentanyl, and hydromorphone, and now needed resuscitation with bag-valve-mask ventilation and naloxone. The incident report read, “anesthesia needs to monitor PACU patients more closely.” The reporter neglected to mention that dosing intervals occurred more frequently than accounted for in the PACU order set (SB).

In reviewing several anonymous safety reports, I uncovered a bully in a leadership role who was poisoning any chance at a culture of safety. Individually, the reports were concerning, but...

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