The audit findings indicate a potential discrepancy in how advanced practice practitioners are being assessed for their eligibility for the Comprehensive Indo-Pacific Orthopaedic Trauma Surgery Advanced Practice Examination. This scenario is professionally challenging because it requires a nuanced understanding of the examination’s purpose and the specific eligibility criteria, which are designed to ensure that only suitably qualified individuals are admitted. Misinterpreting these criteria can lead to either excluding deserving candidates or admitting those who may not yet possess the required competencies, potentially impacting patient care and the reputation of the advanced practice pathway. Careful judgment is required to balance fairness to applicants with the integrity of the examination process. The best approach involves a thorough review of the official examination handbook and any supplementary guidance documents provided by the examination board. This approach is correct because it directly addresses the stated purpose of the examination, which is to validate advanced practice skills and knowledge in orthopaedic trauma surgery within the Indo-Pacific region. Eligibility criteria are meticulously defined within these official documents to ensure candidates possess the necessary academic qualifications, clinical experience, and professional endorsements. Adhering strictly to these documented requirements ensures a fair and objective assessment process, upholding the standards set by the examination body and safeguarding the quality of advanced practice in the field. This aligns with ethical principles of transparency and fairness in professional assessment. An incorrect approach would be to rely solely on informal discussions or anecdotal evidence from colleagues regarding eligibility. This is professionally unacceptable because it bypasses the authoritative source of information, the official examination guidelines. Such an approach risks misinterpreting or misapplying the criteria, potentially leading to incorrect assessments of eligibility. It fails to uphold the principle of objective assessment and can create an uneven playing field for candidates. Another incorrect approach would be to interpret eligibility based on the applicant’s perceived seniority or years of practice without verifying if these align with the specific experience requirements outlined in the examination’s framework. While seniority can be a factor, the examination’s purpose is to assess specific advanced practice competencies, not just tenure. This approach is ethically flawed as it deviates from the defined standards and may admit individuals who lack the specialized skills the examination aims to certify. A further incorrect approach would be to assume that a candidate’s successful completion of a general orthopaedic residency automatically qualifies them for an advanced practice examination in trauma surgery. While foundational knowledge is important, advanced practice examinations typically require specific trauma-related experience and demonstrated competency at a higher level than a standard residency provides. This approach fails to recognize the specialized nature of advanced practice and the distinct requirements of the examination, potentially undermining its purpose of certifying specialized expertise. Professionals should adopt a decision-making framework that prioritizes consulting official documentation as the primary source of truth for examination eligibility. This involves actively seeking out and meticulously reviewing the examination handbook, regulatory guidelines, and any published FAQs or addenda. When ambiguity arises, the professional course of action is to seek clarification directly from the examination board or its administrative body, rather than making assumptions or relying on informal channels. This ensures that decisions are grounded in verifiable standards, promoting fairness, integrity, and the consistent application of eligibility criteria.

Scenario Analysis: This scenario presents a common yet critical challenge in orthopaedic trauma surgery: managing a complex fracture with potential neurovascular compromise while ensuring the safe and effective use of instrumentation and energy devices. The professional challenge lies in balancing the immediate surgical need to address the fracture with the paramount responsibility of patient safety, particularly concerning iatrogenic injury from instrumentation or energy devices. The surgeon must possess a deep understanding of operative principles, meticulous technique, and a proactive approach to risk mitigation. Correct Approach Analysis: The best professional practice involves a systematic and cautious approach. This includes a thorough pre-operative assessment of the fracture pattern, surrounding anatomy, and potential neurovascular structures. During the procedure, meticulous dissection, careful handling of instruments to avoid inadvertent damage to soft tissues or vital structures, and judicious use of energy devices are essential. Specifically, employing energy devices only when necessary for specific tasks like cautery or bone preparation, ensuring adequate irrigation to prevent thermal injury, and maintaining constant awareness of the device’s active tip and its proximity to critical structures are paramount. This approach aligns with the fundamental ethical principles of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm). Regulatory frameworks, such as those governing surgical practice and patient safety, implicitly mandate such diligence to prevent avoidable complications. Incorrect Approaches Analysis: One incorrect approach involves proceeding with aggressive bone preparation using a high-speed drill without adequate visualization or awareness of the adjacent neurovascular bundle. This demonstrates a failure to adhere to the principle of meticulous dissection and a disregard for the potential for iatrogenic injury, violating the duty of care and potentially leading to severe, irreversible harm. Another unacceptable approach is the indiscriminate use of electrocautery in close proximity to nerves or vessels without proper insulation or intermittent application. This shows a lack of understanding of energy device safety protocols and a failure to prioritize patient safety, directly contravening the principle of non-maleficence and potentially violating guidelines on the safe use of surgical energy. A further flawed approach would be to rely solely on the perceived experience of the surgical team without employing systematic checks and balances for instrument and energy device safety. While experience is valuable, it does not negate the need for vigilance, adherence to established protocols, and a culture of safety that encourages questioning and confirmation, especially in complex cases. This approach risks complacency and overlooks potential errors that could be prevented through a more structured safety process. Professional Reasoning: Professionals should adopt a “safety-first” mindset, integrating risk assessment and mitigation into every stage of the operative process. This involves a pre-operative “time out” to confirm patient identity, procedure, and site, as well as a discussion of potential risks and strategies. Intra-operatively, continuous vigilance, clear communication within the surgical team, and a willingness to pause and reassess when uncertainty arises are crucial. For instrumentation and energy devices, this means understanding their specific functionalities, limitations, and potential hazards, and employing them with precision and purpose, always prioritizing the preservation of vital structures.

This scenario presents a professional challenge due to the inherent conflict between a healthcare provider’s duty to their patient and the potential for financial gain or professional advancement. The need for careful judgment arises from the imperative to maintain patient trust, uphold ethical standards, and comply with professional guidelines, particularly in the context of advanced medical practice where patient vulnerability is high. The best professional approach involves transparently disclosing the potential conflict of interest to the relevant institutional ethics committee or review board and seeking their guidance before proceeding with the research. This approach is correct because it prioritizes patient welfare and institutional integrity. By proactively engaging with the ethics committee, the surgeon demonstrates a commitment to ethical research practices and ensures that any potential conflicts are managed in a way that safeguards patient interests and maintains public trust in medical research. This aligns with the fundamental ethical principles of beneficence, non-maleficence, and justice, as well as the professional obligation to act with integrity and transparency. An incorrect approach would be to proceed with the research without any disclosure, hoping that the potential benefits to the institution and the surgeon’s career will outweigh any ethical concerns. This fails to acknowledge the potential for bias in research design, data interpretation, and reporting, which could compromise the validity of the findings and harm future patients. It also violates the principle of transparency and could lead to a breach of trust if discovered. Another incorrect approach would be to disclose the conflict only to the pharmaceutical company funding the research. This is insufficient because the pharmaceutical company has a vested interest in the research outcome, making their assessment of the conflict potentially biased. It fails to involve an independent body that can objectively evaluate the situation and provide unbiased guidance, thereby compromising the integrity of the research process and patient safety. A further incorrect approach would be to withdraw from the research entirely without seeking any guidance or exploring potential mitigation strategies. While avoiding the conflict, this approach may deprive patients of potentially beneficial treatments or advancements in orthopaedic trauma surgery, and it misses an opportunity to learn how to ethically navigate such situations in the future. Professional reasoning in such situations requires a structured decision-making process: first, identify the potential conflict of interest; second, assess the nature and severity of the conflict; third, consult relevant ethical guidelines and institutional policies; fourth, seek advice from an independent ethics committee or trusted senior colleagues; and fifth, implement a management plan that prioritizes patient welfare and research integrity.

This scenario is professionally challenging because it requires balancing the need for fair and consistent assessment with the practical realities of an examination process. The examination board has a responsibility to maintain the integrity and credibility of the qualification. Decisions regarding blueprint weighting, scoring, and retake policies directly impact candidates’ opportunities and the perceived fairness of the assessment. Careful judgment is required to ensure these policies are transparent, equitable, and aligned with the examination’s objectives. The best approach involves a thorough review of the examination’s blueprint and scoring mechanisms by an independent committee. This committee should assess whether the current weighting accurately reflects the knowledge and skills deemed essential for advanced practice in orthopaedic trauma surgery within the Indo-Pacific region. They should also evaluate the scoring rubric for clarity, objectivity, and consistency. Furthermore, the committee should examine the retake policy to ensure it provides a fair opportunity for candidates to demonstrate competence without unduly penalizing them for initial performance, while still upholding the standards of the qualification. This approach prioritizes evidence-based decision-making, fairness, and adherence to the examination’s stated aims, ensuring that any policy changes are well-justified and contribute to the overall quality of the assessment. An approach that focuses solely on candidate feedback without independent validation of the blueprint or scoring is professionally unacceptable. While candidate feedback is valuable, it should not be the sole determinant of policy changes. Relying solely on feedback risks making decisions based on subjective perceptions rather than objective assessment needs, potentially compromising the rigor of the examination. Another professionally unacceptable approach is to implement immediate, drastic changes to retake policies based on anecdotal evidence of candidate dissatisfaction. Such changes, without a systematic review of the examination’s performance data and the underlying rationale for the existing policy, could undermine the established standards and create an inconsistent assessment experience. Finally, an approach that prioritizes expediency by simply adjusting the passing score without re-evaluating the blueprint or scoring criteria is also flawed. This superficial adjustment fails to address any potential underlying issues with the assessment’s design or content validity, potentially leading to a qualification that does not accurately reflect the required competencies. Professionals should approach such situations by establishing a clear, objective process for policy review. This process should involve data analysis, expert consensus, and consideration of the examination’s purpose and the competencies it aims to assess. Transparency with candidates regarding the review process and the rationale behind policy decisions is also crucial for maintaining trust and confidence in the examination.

This scenario presents a professional challenge due to the inherent conflict between a candidate’s desire for efficient preparation and the ethical imperative to maintain the integrity of the examination process. The examination, Comprehensive Indo-Pacific Orthopaedic Trauma Surgery Advanced Practice Examination, is designed to assess advanced competency, and shortcuts in preparation could lead to a misrepresentation of a candidate’s true knowledge and skills, potentially impacting patient care. Careful judgment is required to balance personal study efficiency with professional responsibility. The best approach involves a structured, evidence-based preparation strategy that prioritizes understanding core principles and current best practices, aligning with the ethical obligation to be thoroughly prepared and competent. This includes engaging with peer-reviewed literature, attending reputable workshops and conferences, and practicing case-based scenarios. Such a method ensures that preparation is not only efficient but also robust, directly addressing the learning objectives of the examination and upholding the standards expected of advanced practitioners in orthopaedic trauma surgery. This aligns with the ethical duty of care to future patients and the professional commitment to lifelong learning and competence. An approach that relies solely on memorizing past examination questions and answers, without a deep understanding of the underlying principles, is ethically flawed. This method prioritizes passing the exam through rote learning rather than genuine mastery, which could lead to a superficial understanding of complex trauma scenarios. It fails to equip the candidate with the critical thinking and problem-solving skills necessary for real-world patient management, potentially compromising patient safety and violating the professional duty to provide competent care. Another unacceptable approach is to delegate significant portions of preparation to junior colleagues or trainees. While collaboration is valuable, the ultimate responsibility for examination preparation rests with the candidate. Relying on others to condense or explain complex topics without personal engagement risks overlooking critical nuances or developing an incomplete understanding. This approach undermines the candidate’s personal accountability and the ethical commitment to self-directed professional development. Finally, focusing exclusively on high-yield topics identified through informal channels, without a comprehensive review of the entire syllabus, is also problematic. This strategy risks creating knowledge gaps in less frequently tested but potentially critical areas of orthopaedic trauma. Such an approach prioritizes exam strategy over comprehensive learning, potentially leaving the candidate unprepared for a wider range of clinical situations and failing to meet the ethical standard of thorough preparation. Professionals should adopt a decision-making framework that begins with understanding the examination’s scope and objectives. This should be followed by identifying reliable and comprehensive study resources, including academic literature, professional guidelines, and recognized educational programs. A structured study plan, incorporating active learning techniques and self-assessment, should be developed. Finally, ethical considerations, such as the duty to patients and the integrity of the profession, should guide all preparation choices, ensuring that the pursuit of certification is synonymous with the pursuit of genuine competence.

Scenario Analysis: This scenario presents a significant ethical dilemma for an orthopaedic trauma surgeon operating in the Indo-Pacific region. The challenge lies in balancing the immediate need for a potentially life-saving surgical intervention with the patient’s right to informed consent, especially when the patient’s capacity to understand complex medical information is compromised due to their critical condition and potential language barriers. The surgeon must navigate cultural nuances regarding decision-making within families while upholding universal ethical principles of patient autonomy and beneficence. The pressure of a time-sensitive situation further complicates the decision-making process, requiring a rapid yet ethically sound judgment. Correct Approach Analysis: The best professional approach involves prioritizing the patient’s immediate well-being while diligently seeking the most informed consent possible under the circumstances. This entails clearly and concisely explaining the critical nature of the surgery, the potential benefits, risks, and alternatives in a manner that the patient can comprehend, utilizing a qualified medical interpreter if necessary. If the patient, despite best efforts, cannot provide fully informed consent due to their condition, the surgeon should proceed with the necessary life-saving intervention, documenting extensively the efforts made to obtain consent and the rationale for proceeding under emergent circumstances, and then seeking confirmation from the patient or their designated next-of-kin as soon as feasible. This aligns with the ethical principle of beneficence (acting in the patient’s best interest) when autonomy cannot be fully exercised, and the principle of non-maleficence (avoiding harm) by addressing the immediate life-threatening condition. Regulatory frameworks in most jurisdictions, including those influenced by international medical ethics, support emergent intervention when a patient’s life is at risk and informed consent cannot be obtained in a timely manner, provided thorough documentation and subsequent confirmation are pursued. Incorrect Approaches Analysis: Proceeding with surgery without making every reasonable effort to obtain the patient’s understanding and assent, even in an emergent situation, would be ethically flawed. This fails to respect the patient’s right to self-determination to the greatest extent possible. Similarly, delaying a critical surgery solely to wait for a family member’s consent when the patient is capable of some level of assent, or when the patient’s life is in immediate peril, would violate the principle of beneficence and potentially lead to irreversible harm. Relying solely on the interpretation of a non-medical family member without direct communication with the patient, especially if the patient exhibits any signs of comprehension, bypasses the patient’s inherent right to be involved in their care and can lead to misunderstandings or decisions not aligned with the patient’s wishes. Professional Reasoning: Professionals facing such dilemmas should employ a structured decision-making process. First, assess the patient’s immediate life-threatening condition and the urgency of intervention. Second, evaluate the patient’s capacity to understand and consent, making all reasonable efforts to facilitate comprehension (e.g., using interpreters, simplifying language). Third, if capacity is limited, explore the patient’s previously expressed wishes or values if known. Fourth, if emergent intervention is required and consent cannot be obtained from the patient, involve the designated next-of-kin or appropriate surrogate decision-maker, clearly explaining the situation and the rationale for proposed actions. Fifth, meticulously document all discussions, assessments of capacity, efforts to obtain consent, and the rationale for the chosen course of action. Finally, seek to confirm the decision with the patient or surrogate as soon as medically appropriate.

The performance metrics show a concerning trend in patient outcomes for complex orthopaedic trauma cases, specifically a higher-than-average rate of revision surgeries and delayed union. This scenario is professionally challenging because it directly impacts patient well-being and the reputation of the surgical team and institution. It requires a meticulous and ethically sound approach to operative planning, balancing the urgency of treatment with the need for thorough risk assessment and mitigation. The best approach involves a comprehensive, multidisciplinary pre-operative assessment and detailed operative plan that explicitly addresses identified risks. This includes thorough patient evaluation, advanced imaging review, consultation with relevant specialists (e.g., anaesthesiologists, infectious disease, physiotherapy), and a clear articulation of potential complications and their management strategies within the operative note. This approach aligns with the ethical principles of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm) by proactively identifying and planning for potential adverse events. It also upholds professional accountability by documenting a rigorous planning process. An incorrect approach would be to proceed with surgery based on a standard protocol without specific consideration for the patient’s unique risk factors or the observed performance metric trends. This fails to demonstrate due diligence and could lead to preventable complications, violating the principle of non-maleficence. Another incorrect approach would be to delegate the primary responsibility for risk assessment and planning to junior team members without adequate senior oversight and validation. While teamwork is essential, the ultimate responsibility for patient care rests with the consultant surgeon. This approach risks overlooking critical details and could be seen as a failure of professional leadership and accountability. A further incorrect approach would be to postpone surgery indefinitely due to perceived high risk without exploring all available mitigation strategies or seeking further expert opinions. While caution is warranted, delaying necessary treatment without a clear, evidence-based rationale can also be detrimental to the patient’s outcome, potentially violating the principle of beneficence. Professionals should employ a structured decision-making process that prioritizes patient safety. This involves: 1) Acknowledging and analyzing performance data to identify areas for improvement. 2) Conducting a thorough, individualized patient assessment, considering all relevant medical history, comorbidities, and imaging. 3) Engaging in collaborative planning with the multidisciplinary team. 4) Developing a detailed operative plan that anticipates potential complications and outlines specific mitigation strategies. 5) Documenting the entire process meticulously. 6) Regularly reviewing and updating protocols based on outcomes and new evidence.

The control framework reveals a scenario demanding careful ethical and professional judgment due to the inherent conflict between patient autonomy, the surgeon’s duty of care, and the potential for resource allocation challenges within a high-volume trauma center. The surgeon is faced with a situation where a patient’s wishes, while informed, may not align with what is perceived as the optimal surgical outcome based on anatomical and physiological considerations, potentially impacting long-term function and requiring significant perioperative resources. This necessitates a nuanced approach that respects patient rights while upholding professional standards. The approach that represents best professional practice involves a thorough, shared decision-making process that prioritizes patient understanding and consent, even when the patient’s preference deviates from the surgeon’s initial recommendation. This includes a detailed explanation of the proposed surgical anatomy, the physiological implications of different treatment pathways, and the expected perioperative outcomes. The surgeon must ensure the patient comprehends the risks, benefits, and alternatives, including the potential for suboptimal functional recovery if their preferred, less invasive approach is chosen. This aligns with the ethical principles of beneficence (acting in the patient’s best interest, which includes respecting their informed choices) and autonomy (the patient’s right to self-determination). Regulatory frameworks governing medical practice emphasize informed consent as a cornerstone of patient care, requiring clear, understandable communication about treatment options and their consequences. An approach that involves overriding the patient’s stated preference due to the surgeon’s belief in a superior anatomical or physiological outcome, without further extensive discussion and exploration of the patient’s values, represents a failure to uphold patient autonomy. While the surgeon’s expertise is invaluable, it does not grant them the right to unilaterally dictate treatment when a patient has the capacity to make informed decisions. This could lead to a breach of trust and potential legal challenges related to battery or lack of informed consent. Another professionally unacceptable approach would be to proceed with the patient’s preferred, less optimal surgical plan without adequately documenting the comprehensive discussion of anatomical considerations, physiological consequences, and potential long-term functional deficits. This lack of thorough documentation fails to protect both the patient and the healthcare provider, and it undermines the principle of accountability within the surgical team and the institution. Finally, an approach that involves pressuring the patient to accept the surgeon’s preferred treatment by downplaying the risks of their chosen option or exaggerating the benefits of the surgeon’s recommendation is ethically unsound. This manipulative tactic violates the principle of honesty and can lead to a patient making a decision based on incomplete or misleading information, thereby compromising their autonomy and the integrity of the informed consent process. Professionals should employ a structured decision-making process that begins with a comprehensive assessment of the patient’s understanding and values. This should be followed by a clear, empathetic explanation of the relevant applied surgical anatomy, physiology, and perioperative sciences, tailored to the patient’s comprehension level. The surgeon must then actively listen to the patient’s concerns and preferences, exploring the rationale behind their choices. Shared decision-making, where the patient and surgeon collaboratively arrive at a treatment plan, is paramount. If disagreements persist, seeking a second opinion or involving an ethics committee can be valuable steps. Throughout this process, meticulous documentation of all discussions, patient understanding, and the final agreed-upon plan is essential.

This scenario presents a significant professional challenge due to the inherent unpredictability of complex orthopaedic trauma surgery and the critical need for effective crisis resource management. The surgeon is faced with a sudden, life-threatening complication during a procedure on a patient with multiple comorbidities, demanding rapid, accurate assessment and decisive action under immense pressure. The ethical imperative is to prioritize patient safety and well-being while adhering to professional standards of care and maintaining team cohesion. The correct approach involves immediate, clear communication of the perceived crisis to the entire surgical team, followed by a structured, collaborative problem-solving process. This includes a rapid assessment of the situation, identification of potential causes, and a systematic approach to intervention. The surgeon must delegate tasks effectively, drawing on the expertise of available team members, and maintain a calm, authoritative demeanor to guide the team. This approach aligns with principles of patient-centered care, emphasizing the collective responsibility for patient outcomes and the importance of a systematic response to adverse events. It also reflects best practices in crisis resource management, which advocate for clear communication, shared leadership, and structured decision-making in high-stakes situations. An incorrect approach would be to attempt to manage the crisis in isolation without fully engaging the surgical team. This failure to communicate and delegate risks overlooking critical diagnostic clues or therapeutic options that other team members might identify. It also undermines team morale and can lead to confusion and delayed intervention, potentially compromising patient safety. Ethically, this isolated approach neglects the principle of shared responsibility and the potential for collective expertise to improve patient outcomes. Another incorrect approach is to proceed with a treatment plan without a thorough, albeit rapid, assessment of the underlying cause of the complication. This reactive approach, driven by urgency, can lead to inappropriate interventions that may exacerbate the patient’s condition or introduce new risks. It fails to adhere to the fundamental principle of diagnosing before treating, a cornerstone of sound medical practice. Finally, an incorrect approach would be to become overwhelmed by the situation and exhibit indecisiveness or panic. This can paralyze the team, leading to a loss of precious time and a failure to implement necessary interventions. Professional responsibility demands that the surgeon maintain composure and provide clear leadership, even in the face of unexpected adversity. The professional decision-making process in such situations should involve a mental checklist: Recognize the deviation from the expected course; Assess the severity and potential causes; Communicate the situation clearly to the team; Collaborate on a plan; Execute the plan with clear delegation; and Continuously reassess and adapt.

This scenario presents a professionally challenging situation because it requires balancing the immediate need to address a patient’s adverse outcome with the long-term imperative of systemic quality improvement. The attending surgeon’s emotional distress and potential defensiveness can impede objective review, making a fair and thorough assessment difficult. Careful judgment is required to ensure that the review process is constructive, promotes learning, and upholds patient safety without unfairly penalizing individuals. The best professional approach involves a structured, multi-disciplinary morbidity and mortality (M&M) review process that prioritizes objective data collection and analysis. This approach begins with a comprehensive review of the patient’s case, including operative notes, imaging, pathology reports, and nursing records. The focus is on identifying deviations from best practice, potential contributing factors (including system-level issues and human factors), and opportunities for improvement. The attending surgeon’s participation should be encouraged in a supportive, non-punitive environment where they can provide their perspective and contribute to the learning process. This aligns with the principles of continuous quality improvement mandated by healthcare regulatory bodies, which emphasize a systems-based approach to patient safety and learning from adverse events. The goal is not to assign blame but to understand the ‘why’ behind the outcome to prevent recurrence. An approach that involves immediate, informal discussion with the attending surgeon in a private setting, focusing solely on their perceived errors, is professionally unacceptable. This bypasses established M&M protocols, lacks the objectivity of a multi-disciplinary review, and risks creating an adversarial dynamic that hinders open communication and learning. It fails to consider potential system-level contributions or the broader context of the adverse event, potentially leading to misidentification of root causes. Another professionally unacceptable approach is to defer the M&M review indefinitely due to the attending surgeon’s emotional state. While empathy is important, delaying a critical quality assurance process indefinitely prevents the institution from learning from the event and implementing necessary changes to protect future patients. This inaction represents a failure in the institution’s responsibility to maintain high standards of care and a disregard for the principles of continuous quality improvement. Finally, an approach that involves immediately reporting the attending surgeon to the medical board based on the initial report of the adverse event, without a thorough M&M review, is also professionally unacceptable. Such a premature action bypasses the established internal review mechanisms designed to gather all relevant facts and perspectives. It can lead to an unfair assessment of the surgeon’s performance and undermine the trust necessary for effective M&M processes. Regulatory bodies typically expect institutions to have robust internal review processes in place before external reporting is considered, unless there is immediate and egregious patient harm that necessitates urgent external intervention. Professionals should approach such situations by adhering to established institutional M&M protocols. This involves a commitment to a systematic, data-driven, and multi-disciplinary review process. Key decision-making steps include: 1) ensuring all relevant documentation is collected; 2) involving a diverse team of clinicians and potentially administrators in the review; 3) creating a safe space for open discussion and learning; 4) focusing on identifying system-level factors and human factors alongside individual contributions; and 5) developing actionable recommendations for improvement.