“…Other strategies to reduce the probability of catastrophic outcomes include providing smart alarms (Becker et al, 1994;Westenskow, Orr, Simon, Bender, & Frankenberger, 1992), using intelligent decision support systems (Lowe, Jones, & Harrison, 2001), and providing better training with emphasis on critical event management in high-fidelity patient simulators (Gaba, 1992;Gaba, Fish, & Howard, 1994). Without doubt, a combination of these and other strategies will have the highest impact on reducing catastrophic outcome.…”