Patient-safety failures are often treated as isolated mistakes, even when the real causes are embedded in systems, incentives, standards, and governance. This session presents a practical path from adverse-event analysis to durable reform. Mário explains how to combine clinical evidence, human-factors thinking, legal analysis, stakeholder mapping, and regulatory strategy to identify root causes and redesign safeguards. Using lessons from large-scale national anesthesia-safety reforms, he shows how technical findings can become institutional standards without losing scientific rigor.

For healthcare executives, quality and safety teams, clinicians, regulators, policymakers, and legal professionals. 45–60 minutes; suitable for keynote, grand rounds, or leadership workshop.