expand the following: In the context of teamwork and patient safety, the case presented likely involved several barriers listed by Leonard et al. (2005). For instance, hierarchy within the team might have hindered effective communication and decision-making, leading to a lack of collaboration and a failure to address concerns from lower-ranking team members. Additionally, defensiveness among team members could have prevented open discussion about potential risks or errors, further exacerbating the situation. Moreover, distractions, fatigue, and a heavy workload could have compromised team members' ability to focus and maintain vigilance, increasing the likelihood of errors or oversights. To improve teamwork and mitigate the risk of similar adverse events, several process changes can be implemented. Firstly, fostering a culture of psychological safety where all team members feel comfortable speaking up about safety concerns without fear of retribution is crucial. This can be achieved through regular team training sessions focusing on effective communication, conflict resolution, and mutual respect. Additionally, creating structured protocols for team interactions, such as regular team meetings and debriefings, can facilitate collaboration and ensure that all team members are on the same page regarding patient care plans. Implementing tools or checklists to standardize communication styles and clarify roles and