Dr. Karen Rigamonti

10/09/2026

A friend of ours spent most of a day in a busy emergency department not long ago, after a brief loss of consciousness. At his age, that should start a cardiac workup and monitoring right at triage. He was sent to the waiting room.

Hours later, the attending came in to recommend admission for fluids and cardiac monitoring. As she listed her reasons, she realized he had received only one liter of fluid, and the monitor had never been connected. The leads had been on his chest the whole time.

He is fine. Every test came back normal. I keep thinking about the patients whose stories end differently.
Everyone who cared for him that day was capable. Each of them assumed someone else had taken the next step, and no one told him or his family who was in charge or what would happen next.

I wrote about what happened, and three simple changes that would have made his care safer, on my blog. (Link in the comments)

Have you or someone you love sat in an emergency department wondering who was in charge? I would like to hear about it in the comments.

08/26/2026

08/26/2026

Not a hoarder, I’ m a collector

07/22/2026

Think about the most effective post-event review you've seen in a healthcare setting.

Not the most thorough in terms of documentation. The one that actually produced a change that held.

𝗪𝗵𝗮𝘁 𝗱𝗶𝗱 𝗶𝘁 𝗱𝗼 𝗱𝗶𝗳𝗳𝗲𝗿𝗲𝗻𝘁𝗹𝘆?

The reviews that produce lasting change tend to share a specific quality, and in our experience it's rarely about the rigor of the individual factor analysis. 𝘾𝙪𝙧𝙞𝙤𝙪𝙨 𝙬𝙝𝙖𝙩 𝙤𝙩𝙝𝙚𝙧𝙨 𝙝𝙖𝙫𝙚 𝙤𝙗𝙨𝙚𝙧𝙫𝙚𝙙.

07/16/2026

𝙄𝙣 𝙨𝙪𝙧𝙜𝙚𝙧𝙮, 𝙬𝙚 𝙡𝙚𝙖𝙧𝙣𝙚𝙙 𝙩𝙝𝙖𝙩 𝙘𝙤𝙢𝙥𝙡𝙞𝙘𝙖𝙩𝙞𝙤𝙣𝙨 𝙖𝙡𝙢𝙤𝙨𝙩 𝙣𝙚𝙫𝙚𝙧 𝙘𝙤𝙢𝙚 𝙛𝙧𝙤𝙢 𝙤𝙣𝙚 𝙩𝙝𝙞𝙣𝙜.

They come from how multiple things interact at the same time. The handoff that happened but didn't carry the full picture. The concern that felt too uncertain to raise yet. The decision made under pressure with the information available. The staffing pattern that made all of it more likely to land on the same day.

Any one of those, on its own, might not have changed the outcome. Together, in that particular combination, they did.

Healthcare organizations work the same way. When a serious event gets reviewed, the contributing factors usually get found and each one gets addressed. But the interaction between them, how factor A made factor B harder to catch, how factor B made factor C more likely to escalate, often goes unexamined.

Fix the parts and the interaction pattern can remain largely intact. That's where recurrence lives.

One question worth adding to every review, before the action plan gets written:
"How were these factors connected, and does that connection still exist?"

07/09/2026

"𝙒𝙚 𝙛𝙞𝙭𝙚𝙙 𝙩𝙝𝙚 𝙞𝙣𝙥𝙪𝙩𝙨. 𝙏𝙝𝙚 𝙨𝙮𝙨𝙩𝙚𝙢 𝙩𝙝𝙖𝙩 𝙘𝙤𝙣𝙣𝙚𝙘𝙩𝙚𝙙 𝙩𝙝𝙚𝙢 𝙨𝙩𝙖𝙮𝙚𝙙 𝙩𝙝𝙚 𝙨𝙖𝙢𝙚."

A patient safety officer said this to us about eighteen months after a significant adverse event. The investigation had been thorough. The corrective action had been real. The effort was genuine.

And still, a familiar pattern had begun to take shape.

Not because anything was done wrong. Because the standard investigation process is designed to find causes, not to map how causes feed each other over time.

Fixing the communication gap is necessary. So is asking what that gap was making more likely. And whether that chain still exists in some form, even after the gap itself has been closed.

That second question is where durable improvement tends to live.
Graphic overlay: Fixing parts does not always change the pattern.

07/07/2026

For every charge nurse, physician, administrator, and frontline worker who has ever thought: "𝘵𝘩𝘦𝘴𝘦 𝘤𝘰𝘯𝘥𝘪𝘵𝘪𝘰𝘯𝘴 𝘬𝘦𝘦𝘱 𝘴𝘩𝘰𝘸𝘪𝘯𝘨 𝘶𝘱 𝘵𝘰𝘨𝘦𝘵𝘩𝘦𝘳, 𝘢𝘯𝘥 𝘴𝘰𝘮𝘦𝘥𝘢𝘺 𝘵𝘩𝘢𝘵'𝘴 𝘨𝘰𝘪𝘯𝘨 𝘵𝘰 𝘮𝘢𝘵𝘵𝘦𝘳."

You're probably right.

The people closest to the work are often the ones who can see the interaction pattern most clearly. The staffing situation and the documentation burden and the handoff timing that keep colliding on certain shifts. The communication dynamic between two teams that consistently leaves something in a gap. The near-miss that happened quietly and didn't generate a formal review.

That knowledge is exactly what's missing from most post-event investigations. Not because anyone excluded it. Because the process doesn't reliably create a path for it to arrive.

If you're a leader: the people on your team who are quietly managing a combination of conditions are holding part of the picture you need. Ask them directly, before the next event creates the occasion.