The development of a working environment in which communication flows freely—as in the aviation industry where the “two-challenge rule” is practiced— is essential to the growth of an institutional safety culture.24 The Institute of Medicine has agreed: “Designing systems for safety requires specific, clear, and consistent efforts to develop a work culture that encourages reporting of errors and hazardous conditions, as well as communication among staff about safety concerns.”25 In an effort to further enhance patient safety, build front-line staff confidence, and illustrate the responsiveness and support of management to the BCMA end-users, the collaborative team and management established Patient Safety Rounds, which is modeled after the Beth
