How would you redesign a discrepancy meeting so a recurring failure actually changes?

Instruction: Describe the meeting format and one completed improvement cycle, keeping immediate patient care and formal incident processes separate from educational discussion.

Context: At this fictional department’s learning meetings, screenshots are shown with the diagnosis already revealed and colleagues feel personally ranked. Three recent cases involved a significant report change that never reached the responsible team after transfer between wards. You have been asked to redesign the next meeting and its follow-through.

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The ward-transfer failure gives us a concrete first improvement project. Before the meeting, someone must establish whether those patients still need a correction or clinical action; patient care must not wait for an educational meeting...

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