The recently publicized reports of children dying from Aspergillus fungal infections once again brings into question the culture around reporting errors in U.S. hospitals. Twenty years ago, the Institute of Medicine broke the silence about the epidemic of patient harm from medical errors in health care facilities. The report, “To Err is Human: Building a Safer Health System,” estimated that 98,000 patients died annually from avoidable harm caused by medical errors. Despite the horror of this figure, hospitals still struggle to learn from such near mistakes. Financial penalties from the government, patient and family lawsuits, fear of job loss, psychological constructs of clinicians, and a culture of blame make candid root cause analysis of steps leading up to patient injury almost impossible. Despite these difficulties, the status quo of silence around unintended harm in medicine has to stop. This can only be done by looking at facts and collecting and analyzing data on the underlying dynamics in hospitals.
In this case, two important issues have been raised.