{"id":458152,"date":"2026-02-09T12:20:11","date_gmt":"2026-02-09T12:20:11","guid":{"rendered":"https:\/\/www.newsbeep.com\/us\/458152\/"},"modified":"2026-02-09T12:20:11","modified_gmt":"2026-02-09T12:20:11","slug":"patients-families-suffer-due-to-lack-of-transparency","status":"publish","type":"post","link":"https:\/\/www.newsbeep.com\/us\/458152\/","title":{"rendered":"Patients, families suffer due to lack of transparency"},"content":{"rendered":"

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<\/a> in Jerusalem and taught evidence-based medicine and public health at the Hebrew University of Jerusalem<\/a>.\u00a0<\/p>\n

Sadly, in 2021, his own grandson \u2013 three-and-a-half-year-old Amit Brezis \u2013 died tragically due to a medical error by a health fund. The blond, curly-haired toddler was born with a complex heart<\/a> 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.<\/p>\n

Ultrasounds can detect fetal heart defects early, but in Amit\u2019s case, the delay complicated surgery due to severe pulmonary hypertension, and the need for ECMO (a life-support system) resulted in paraplegia \u2013 loss of motor and sensory function in the lower body.<\/p>\n

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.<\/p>\n

In the US, the Centers for Disease Control<\/a> 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\u2019s 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.<\/p>\n

\"PROF.PROF. MAYER BREZIS\u2019S late grandson, three-year-old Amit Brezis, died as a result of a medical error. (credit: Courtesy)<\/p>\n

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.<\/p>\n

Brezis has just published an article in Risk Management and Healthcare Policy under the title \u201cWhy Do We Fail at Reducing Medical Errors? Assuming Responsibility to Leverage Failure into Improvement.\u201d<\/p>\n

Such errors, he told The Jerusalem Post in an interview, occur because \u201cthe greatest barriers to patient safety are not technological or scientific \u2013 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 \u2018deny and defend\u2019 approach prevents meaningful correction and allows the same errors to recur. We must link failure to repair by taking responsibility.\u201d<\/p>\n

Kintsugi, tikkun olam, and the importance of failure in growth<\/p>\n

Brezis pointed out that \u201cKintsugi\u201d (or \u201cGolden Joinery\u201d) 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 \u2013 from Albert Camus to Lord Rabbi Jonathan Sachs \u2013 a proper response to the absurd in tragedies is to stand up for improvement \u2013 tikkun olam (\u201crepairing the world\u201d). 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\u2019s disaster into another child\u2019s survival.\u201d<\/p>\n

AFTER AMIT\u2019S tragedy, Brezis became obsessed with reducing the risk of similar errors in other families.<\/p>\n

When there\u2019s tragedy, Brezis nobly stated, \u201cIf medical professionals can learn and improve from it, it\u2019s meaningful. Einstein said, \u2018The only real mistake is the one from which we learn nothing.\u2019\u201d<\/p>\n

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.<\/p>\n

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\u2019s skill and performance.<\/p>\n

Institutions hire lawyers to avoid admitting errors. \u201cThere must be a different organizational culture. I found a refusal to link failure with correction. The health fund where an ultrasound missed my grandson\u2019s heart defect rejected responsibility for the failure and the pursuit of improvement, including the possible use of AI for better accuracy,\u201d Brezis said.<\/p>\n

Following Amit\u2019s 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\u2019s death, but officials at the Health Ministry\u2019s National Council ignored experts\u2019 recommendations to implement it.<\/p>\n

After Amit\u2019s mother\u2019s 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.<\/p>\n

Medical students fear retaliation<\/p>\n

\u201cIf a medical student spots an error, they can either report it or fear retaliation,\u201d said Brezis. \u201cMany 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.<\/p>\n

\u201cMistakes 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.\u201d<\/p>\n

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\u2019 families, for whom correction is part of healing.<\/p>\n

\u201cFar 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,\u201d he concluded.<\/p>\n

He said hopefully that he is \u201coptimistic that the situation can and will eventually change, but this will demand concerted challenging efforts to shift system culture toward transparency and accountability.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"Prof. Mayer Brezis has dedicated most of his professional life to preventing medical errors. A trained nephrologist, he…\n","protected":false},"author":2,"featured_media":458153,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[59],"tags":[184015,97,252,137331,253,60192,101857,1493],"class_list":["post-458152","post","type-post","status-publish","format-standard","has-post-thumbnail","category-health-care","tag-hadassah-hospital","tag-health","tag-health-care","tag-health-ministry","tag-healthcare","tag-healthcare-system","tag-hebrew-university-of-jerusalem","tag-hospital"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/458152","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/comments?post=458152"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/458152\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media\/458153"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media?parent=458152"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/categories?post=458152"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/tags?post=458152"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}