Care of the very sick infant can be complicated by extraneous factors that challenge the cohesiveness of the health care team. Chaos results from low levels of professional agreement and certainty about outcomes and manifests in stress and miscommunication among care providers. This milieu is fertile ground for errors of commission and omission. Effective communication and collaboration are recognized as essential for reducing medical errors in such stressful environments. This article describes a multidisciplinary conference, the Comprehensive Care Rounds, at a neonatal intensive care unit of a Magnet-recognized midwestern pediatric hospital. The Comprehensive Care Round provides a forum for open communication among team members and builds on the hospital's efforts at systems approach to developing a culture of safety and quality.