Fatal hospital errors raise concern over culture of safety

Re “Nightmare end to routine hospital visit: Boston Children’s pays $15 million over death of infant undergoing sleep study” (Page A1, April 30): A $15 million settlement without either a trial or a confidentiality agreement seems to me to be a clear admission that whatever went wrong was entirely foreseeable as well as preventable. My concern is whether Boston Children’s Hospital has adequately examined why it happened in the first place.

I have worked in chemical plants, both before the creation of the Occupational Safety and Health Administration and as recently as seven years ago. OSHA’s position is that all accidents are foreseeable and preventable, and severe penalties are levied when a worker is seriously injured or killed. In manufacturing, making sure it doesn’t happen again isn’t good enough. This has resulted in a significant cultural change in companies that did not take safety seriously before OSHA.

One important technique for accident prevention is the reporting and investigation of so-called near misses. I have personal experience of medical near misses in hospitals, and, in every case, the staff either ignored the event, denied that it had even happened, or suggested that it was of no concern because no one was injured. Never was it mentioned that steps would be taken to prevent the same error from happening again. I believe that medical safety will not improve significantly until there is a cultural change in the field where near misses are viewed as learning opportunities to be recorded and investigated rather than embarrassments best swept under the rug.

JAMES W. SLACK

Lexington