Workarounds can occur when workers do not feel safe enough to speak up and make suggestions to improve the system.

When asked why she thought the regulators chose deference even though they possessed this power, her answer was succinct: “they are coming from a place of fear.

The absence of a Director of Nursing at the time of Lehman's admittance, a post that had been vacant for over a year, also signals that the medical and clinical teams did not adequately appreciate the interdependence and complexity of their work.

A culture of silence is thus not only one that inhibits speaking up but one in which people fail to listen thoughtfully to those who do speak up – especially when they are bringing unpleasant news.

I don't mean to imply that working in a fearless organization takes more effort or a tremendously difficult undertaking. It doesn't. But initially, when we've been entrenched in fear and its attendant mental frameworks, it's not always obvious.