Wow! What a day it has been today; so much great information from several outstanding speakers. One of the biggest take homes from today for me is don’t underestimate the effect you (nurse, resident, intern, attending, etc.) can have on the quality and safety of every patient. After hearing the touching story about Lewis Blackman and hearing from his mother, one realizes that because no one person on the healthcare team owned the issue or escalated it while it was occurring a tragic outcome occurred. As a nurse, this to me is so upsetting because I have always try to be a patient advocate in every way possible and achieve the best care for my patients. Lewis’s story made me realize how important it is to do that for each and every patient because ulitmately it could save their life.