A tragic death: a time to blame or a time to learn?

A “just culture” is needed if patient safety is to be advanced. A teenage girl died earlier this year at Duke University Medical Center after a heart-lung transplant when the donor turned out to be ABO incompatible.1 The circumstances were particularly tragic and poignant; the funds for her procedure had been raised by concerned citizens in support of her desperate parents who had taken quite extraordinary steps to save the life of their daughter. The surgeon who requested and accepted the organs assumed that ABO compatibility had been established. The error was detected only after the procedure had been completed. In spite of every effort, life support had to be withdrawn some 2 weeks later when brain death became evident after a second transplant. The response of the hospital and its staff appears to have been exemplary. Responsibility for the disaster was accepted, everyone was kept fully informed, an urgent investigation was undertaken, and measures to prevent a recurrence immediately instituted.1 However, matters were made extraordinarily difficult for all involved, including her family, by an incendiary media frenzy. In the short time since her tragic death there has been much comment on the events leading to it and on what is needed to prevent this happening again.1–3 But there are also crucial lessons to be learned from the way in which it has been reported and written about. …