The first mistake this organization made was treating each clinical department as its own island. The separate communication tool worked well within one area. The breakdown occurred when interdepartmental exchanges needed to happen and patients’ lives were put on the line when staff had difficulty communicating. The typical care episode involves healthcare professionals from a variety of disciplines providing care at various times of the day. Patient care also includes non-clinical staff members, like transport and environmental services, who need to be reached and involved in parts of the care plan. With all of the roles, schedules, and locations at play, it’s critical to take an enterprise approach to care team collaboration.