Prof. Mayer Brezis has dedicated most of his professional life to preventing medical errors. A trained nephrologist, he served as the longtime director of a Center for Quality and Safety at Hadassah-University Medical Center in Jerusalem and taught evidence-based medicine and public health at the Hebrew University of Jerusalem.
Sadly, in 2021, his own grandson – three-and-a-half-year-old Amit Brezis – died tragically due to a medical error by a health fund. The blond, curly-haired toddler was born with a complex heart defect that was discovered when he was just a year old. It was missed during a pregnancy ultrasound by the health fund and again after his birth.
Ultrasounds can detect fetal heart defects early, but in Amit’s case, the delay complicated surgery due to severe pulmonary hypertension, and the need for ECMO (a life-support system) resulted in paraplegia – loss of motor and sensory function in the lower body.
Pulse oximetry, a quick, painless, noninvasive test that measures oxygen saturation using a sensor on the finger or toe, was not performed on Amit at birth. If done, the heart defect might have been treated earlier, likely saving his life, Brezis stated.
In the US, the Centers for Disease Control and Prevention found that pulse oximetry screening at birth reduces infant mortality by a third. It was voluntarily adopted over a decade ago at Jerusalem’s Shaare Zedek Medical Center and Hillel Jaffe Medical Center in Hadera, but not in other hospitals. Brezis said early diagnosis and surgical treatment of congenital heart defects can often lead to near-normal life expectancy.
A year later, after an elective catheterization, Amit needed two hours of resuscitation, ECMO, and a month of intensive care, and he miraculously recovered. Despite his disability, he was a happy, curious, loving, and loved child. Pulmonary hypertension persisted despite oxygen and three medications (one via infusion pump). He died from a pulmonary hypertensive crisis on Yom Kippur Eve in 2021.
Brezis has just published an article in Risk Management and Healthcare Policy under the title “Why Do We Fail at Reducing Medical Errors? Assuming Responsibility to Leverage Failure into Improvement.”
Such errors, he told The Jerusalem Post in an interview, occur because “the greatest barriers to patient safety are not technological or scientific – but cultural. Fear of legal consequences, institutional defensiveness, and a widespread reluctance to acknowledge responsibility frequently lead healthcare organizations to deny or conceal mistakes rather than learn from them. This ‘deny and defend’ approach prevents meaningful correction and allows the same errors to recur. We must link failure to repair by taking responsibility.”
Kintsugi, tikkun olam, and the importance of failure in growth
Brezis pointed out that “Kintsugi” (or “Golden Joinery”) is the Japanese art of repairing objects by joining fragments with gold. It represents a concept that highlights the beauty of flaws and the importance of failure in growth. According to various thinkers – from Albert Camus to Lord Rabbi Jonathan Sachs – a proper response to the absurd in tragedies is to stand up for improvement – tikkun olam (“repairing the world”). After death, donating organs out of pain and brokenness gives life and hope. When facing a loss caused by a mistake, a goal of restoring sanity is to prevent similar future failures: turning one child’s disaster into another child’s survival.”
AFTER AMIT’S tragedy, Brezis became obsessed with reducing the risk of similar errors in other families.
When there’s tragedy, Brezis nobly stated, “If medical professionals can learn and improve from it, it’s meaningful. Einstein said, ‘The only real mistake is the one from which we learn nothing.’”
Medical errors are among the leading causes of death globally, rivaling heart disease and cancer, but healthcare systems struggle to reduce them. Medicine has advanced in treating illness, but has made less progress in preventing avoidable harm.
Health funds and clinics perform fetal ultrasounds on pregnant women, but many are inadequate, missing nearly half of heart defects. Routine tests in busy primary healthcare units are rushed with little quality control. Brezis stated that healthcare rewards based on procedure quantity over quality, and ultrasound quality heavily relies on the operator’s skill and performance.
Institutions hire lawyers to avoid admitting errors. “There must be a different organizational culture. I found a refusal to link failure with correction. The health fund where an ultrasound missed my grandson’s heart defect rejected responsibility for the failure and the pursuit of improvement, including the possible use of AI for better accuracy,” Brezis said.
Following Amit’s case and an appeal to the Health Ministry, the Israel Association for Neonatology made pulse oximetry screening mandatory for all newborns, as done in countries like the US. It could have been adopted a decade ago, preventing Amit’s death, but officials at the Health Ministry’s National Council ignored experts’ recommendations to implement it.
After Amit’s mother’s request, the association agreed to name the screening after him; however, the Israel Medical Association (IMA) rejected the proposal, fearing it would set a precedent for assuming responsibility. Yet, all Israeli hospitals have adopted the screening, which is estimated to reduce the number of undiagnosed critical heart defects from 76 to 31 annually.
Medical students fear retaliation
“If a medical student spots an error, they can either report it or fear retaliation,” said Brezis. “Many healthcare workers hesitate to speak up due to fear of blame. Evidence from healthcare and high-risk fields shows that a lack of psychological safety leads to more failures.
“Mistakes become deadly when systems refuse to learn from them. Acknowledging failure and assuming responsibility are not about blame but about preventing future tragedies and making sense of suffering.”
He sought data on missed heart defects causing lawsuits in Israel for a cost-utility analysis of AI in pregnancy ultrasounds. Health funds, insurers, and the ministry refused, citing confidentiality or unavailability, thus violating the freedom of information law and hiding errors. Brezis noted this attitude hampers accountability and insults victims’ families, for whom correction is part of healing.
“Far from being a sign of mental weakness or bad luck, making mistakes and learning from them are essential for human consciousness and growth, as errors drive scientific progress. Recognizing their value and taking responsibility opens a critical path to improvement,” he concluded.
He said hopefully that he is “optimistic that the situation can and will eventually change, but this will demand concerted challenging efforts to shift system culture toward transparency and accountability.”