I’m lighting this candle today for my dad, Ernst Both, who died 12-days after he walked into a hospital for an overnight left carotid endarterectomy procedure. During the surgery his heart rate went to 38bpm and his blood pressure to 38/20. 3-units of blood later and a combination of 32 doses of 18 different drugs over the next day and a half, led to a bizarre sequence of adverse drug events that led to 145 doses of 29 different drugs being administered over the first 7-days in the hospital. Atrial fibrillation, wheezing, stridor, angioedema, anxiety, agitation, aggressiveness, delirium, COPD, hypertension, intubation, pneumonia, central line placement, hematuria, “bladder spasms”, gross hematuria, sepsis, and multi-system organ failure. It was a combination of events that may never have occurred if a program like TeamSTEPPS was used to improve communication and teamwork within this hospital, putting the patient and the family members at the top of the Team Structure pyramid.