My father-in-law passed away May 4, 2013, the day of our daughter's senior prom. He was 10 days post CABG, and suffered a pulmonary embolism. This should not have happened - he was 74, otherwise healthy, and had discharged home on post-op day 4. This was not due to any one person or entity's fault, as many things contributed to this event (mother-in-law refused HH visits; unclear on need for blood thinners; unclear on activity level; potential delays in the ED; etc...). I work in patient safety, and events like this are why I do what I do every day.