is the result of something going wrong. • * One of XBE’s goals in processing a ‘Sombrero’ is to make them not happen again. • * When someone has a broken arm, of course you want to fi x it, but maybe also fi nd out the monkey bars aren't safe? • * And sometimes someone comes in with a broken arm and asks for antibiotics. So, when I fi gure out what went wrong, I'm like, oh, you need a cast! • * Or perhaps it's like a doctor's appointment. Sometimes you just want the prescription, but you should know the doctor will ask questions… •