Toward Improving Patient Safety: Systems-Based Approaches Are Our Best Way Forward

In this issue of JAMA Internal Medicine, Baker and colleagues¹ present the case of a woman in her 90s who experienced fatal complications after implantation of a cardiac resynchronization therapy pacemaker (CRT-P). The authors make educational points in this Teachable Moment about the possible harms of placing a device in a high-risk patient with less than clear indications. There is, however, more we can learn from this story.