I agree the checklist process should be in place everywhere, every hospital and it was an unfortunate event by every means.  The CIO was quick to respond as well to improve the current process as they did have one in place, but they are working at making things better and also the CEO was up front and posted on his blog as well. 

Just one other note from the aviation side of things, they mess up too and when you have a blizzard going on, the crew rushed to meet their schedule, they have mistakes too, as the first officer might have a better overall inspection in 70 degree sunny weather versus below zero weather with a physical inspection of the jet in preparation for flight.  Point in case is what’s happening at the time in the environment makes one big difference too on how the checks and balances are done, both aviation and healthcare, thus the real need for a time out to double check and take a deep breath.  There are some hospitals too that don’t have a procedure, and I would guess this would be some of the paper facilities.  It is so important that the World Health Organization created a check list just for that purpose and let’s hope it catches on quickly.  BD 

So, here’s a question: Would you fly on an airline whose pilots didn’t follow routine checklists before takeoff? A few decades ago, the question wasn’t purely academic. Major airlines regularly operated based on the experience of individual pilots. But a series of spectacularly horrible plane crashes transformed the airline industry worldwide. And today, no pilot would think of lifting off a runway without following a series of consensus-driven steps and checking off specific tasks verbally or electronically.

As the head of the SCOAP project, Dr. David Flum, told The Seattle Times late last month, “It seems totally obvious. They’ve been doing this in aviation for four decades, yet it's been totally absent in health care because there's no system to make sure it happens."

http://healthcare-informatics.com/ME2/dirmod.asp?sid=349DF6BB879446A1886B65F332AC487F&nm=&type=Blog&mod=View+Topic&mid=67D6564029914AD3B204AD35D8F5F780&tier=7&id=D3655E2BC50E4EDA8041702F33700C1B

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