by Wendy Johnson

Every once in a while, a hospital error comes to light that's so tragic and egregious, it makes national news headlines and holds our attention: Josie King, the child who died at Johns Hopkins Hospital due to severe dehydration and a medication error; Jesica Santillan, who died after receiving organs with the wrong blood type at Duke University Hospital.

This month, we learned of the latest shocking error; massive radiation overdoses at Los Angeles-based Cedars-Sinai Medical Center.

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Although no deaths have resulted, this potentially deadly mistake went unnoticed for 18 months and impacted more than 200 patients.

At the heart of such errors, no doubt, are communication breakdowns, flawed work processes and documentation errors. In fact, these deficiencies likely form the basis of many of the 40,000 errors that occur in the healthcare delivery system every day.

Many hospitals have made great strides toward reducing errors and improving patient safety--including Johns Hopkins, which is now viewed as a driving force in patient safety. But other organizations continue to fall down, including some of the largest, top-funded and best-known healthcare systems in the nation.

So this begs the question: What small--and large--steps could be taken at your own organization to reduce errors and improve safety?

Where are leaders and front-line staff falling short? Where are we excelling and what can we learn from other's success? And perhaps most importantly; what have you done today to prevent a mistake?

Wendy Johnson is a healthcare journalist and publisher of FierceHealthcare and Hospital Impact.