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He, in other words, accepted the blame as well as the accountability for an assumption that the entire system made (that the blood types were compatible). To the credit of both Duke and the surgeon involved, there was never a protracted attempt to shirk accountability or a reluctance to disclose the error. But in the minds of far too many Americans who saw or heard that statement, the case was closed because the surgeon was now identified as being responsible for the death, rather than the medical center’s system.

In medicine, that is extremely difficult in an atmosphere of apprehension over potential litigation and corresponding “discovery” motions seeking to ferret out even the most innocuous close call or mistake. The adverse interaction of the medical and legal worlds has driven a vast reservoir of clinical knowledge of noncatastrophic misadventures and mistakes underground and has seriously retarded the ability of health care to communicate lessons from even the most publicized and exposed medical disasters.

While some researchers have challenged the accuracy of the IOM’s numbers (4), there appears to be general agreement that the problem of medical errors is serious and one that, while highlighted and publicized by the IOM 1999 report, has long existed. 7% suffered an adverse event for which the provider would likely be found liable (5). The 1999 IOM report noted that the addition of nonhospital errors may drive the numbers of errors and deaths much higher, since hospital patients represent only a small proportion of the total population at risk and many patients increasingly receive complex care in ambulatory settings such as outpatient surgical centers, physicians’ offices, and clinics.