Children's Hospital investigated five patient deaths from deadly fungal disease in 2009.

Jonathan Duffy; Julie Harris; Lalitha Gade; Lynne Sehulster; Emily Newhouse; Heather O'Connell; Judith Noble-Wang; Carol Rao; Arunmozhi Balajee; Tom Chiller

Newspaper/Magazine Article

Children's Hospital investigated five patient deaths from deadly fungal disease in 2009.

April 30, 2014

Duffy J, Harris J, Gade L, et al. The Pediatric infectious disease journal. 2014;33(5):472-6.

View more articles from the same authors.

Reporting on the investigation into an incident where five pediatric patients died after acquiring a health care–associated infection, this newspaper article describes how delays in diagnosis and treatment along with inadequate communication contributed to patient harm.

Free full text

Related journal article

Related Resources From the Same Author(s)

Anatomy and pathophysiology of errors occurring in clinical radiology practice.

August 4, 2010

Disclosing errors and adverse events in the intensive care unit.

April 5, 2006

Standard drug concentrations and smart-pump technology reduce continuous-medication-infusion errors in pediatric patients.

July 20, 2005

Near misses and unsafe conditions reported in a Pediatric Emergency Research Network.

September 23, 2015

December 2, 2015

Description and factors associated with missed nursing care in an acute care community hospital.

October 17, 2018

Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes.

October 19, 2016

A simulation-based evaluation of methods to estimate the impact of an adverse event on hospital length of stay.

October 24, 2007

It depends who you ask: divergences in staff and external stakeholder narratives about the causes of a healthcare failure.

November 29, 2023

Surgical specimen identification errors: a new measure of quality in surgical care.

April 11, 2007

Workplace empowerment and magnet hospital characteristics as predictors of patient safety climate.

June 25, 2008

Student-observed surgical safety practices across an urban regional health authority.

July 6, 2011

Impact of opioid administration in the intensive care unit and subsequent use in opioid-naïve patients.

June 9, 2021

Can patients contribute to enhancing the safety and effectiveness of test-result follow-up? Qualitative outcomes from a health consumer workshop.

June 2, 2021

An effort to improve electronic health record medication list accuracy between visits: patients' and physicians' response.

March 19, 2008

Improving efficiencies and patient safety in healthcare through human factors and ergonomics.

March 23, 2011

Improving patient safety by practicing in a just culture.

July 12, 2017

Silent witnesses: faculty reluctance to report medical students' professionalism lapses.

November 28, 2018

Paramedic intubation errors: isolated events or symptoms of larger problems?

March 15, 2006

Advancing interprofessional patient safety education for medical, nursing, and pharmacy learners during clinical rotations.

November 30, 2016

A systematic review of nursing practice workarounds.

October 19, 2022

Understanding ultrarare adverse events - lessons learned from a twelve-year review of intraoperative deaths at an academic medical center.

June 21, 2023

Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III.

March 27, 2005

The impact of health information technology on the management and follow-up of test results—a systematic review.

May 8, 2019

Older adults' perceptions of feeling safe in urban and rural acute care.

March 27, 2013

Probability error in diagnosis: the conjunction fallacy among beginning medical students.

July 1, 2009

An asset-based quality improvement tool for health care organizations: cultivating organization wide quality improvement and health care professional engagement.

October 19, 2022

A new infusion syringe label system designed to reduce task complexity during drug preparation.

June 27, 2007

Strategies for improving communication in the emergency department: mediums and messages in a noisy environment.

July 24, 2013

The delivery of safe and effective test result communication, management and follow-up.

September 27, 2023

When order sets do not align with clinician workflow: assessing practice patterns in the electronic health record.

June 19, 2019

Use of multidisciplinary rounds to simultaneously improve quality outcomes, enhance resident education, and shorten length of stay.

July 25, 2007

Scaling up a diagnostic pause at the ICU-to-ward transition: an exploration of barriers and facilitators to implementation of the ICU-PAUSE handoff tool.

September 27, 2023

Retrospective review of emergency response activations during a 13-year period at a tertiary care children's hospital.

December 22, 2010

Outcomes after out-of-hospital endotracheal intubation errors.

February 18, 2009

Burnout in the nursing home health care aide: a systematic review.

August 31, 2016

September 15, 2021

Reasons for repeat rapid response team calls, and associations with in-hospital mortality.

February 6, 2019

Underreporting of patient safety incidents reduces health care's ability to quantify and accurately measure harm reduction.

November 17, 2010

Organizational learning in hospitals: a realist review.

August 21, 2019

Infection control assessment of ambulatory surgical centers.

June 23, 2010

The top 10 list for a safe and effective sign-out.

November 5, 2008

'Not another safety culture survey': using the Canadian patient safety climate survey (Can-PSCS) to measure provider perceptions of PSC across health settings.

November 13, 2013

Management-changing errors in the recall of radiologic results—a pilot study.

July 25, 2012

Patient safety in obstetrics: what aviators, firefighters and others can teach us.

July 9, 2008

The need for risk profiling in patient safety.

September 15, 2010

The quest to eliminate intrathecal vincristine errors: a 40-year journey.

March 31, 2010

What has change management in industry got to do with improving patient safety?

January 30, 2005

Family alert: implementing direct family activation of a pediatric rapid response team.

October 28, 2009

Emergency department visits for medical device–associated adverse events among children.

September 15, 2010

Bar-coding surgical sponges to improve safety: a randomized controlled trial.

April 23, 2008

Regional variations in diagnostic practices.

May 12, 2010

Missed diagnosis of cardiovascular disease in outpatient general medicine: insights from malpractice claims data.

August 16, 2017

Prevention of pediatric medication errors by hospital pharmacists and the potential benefit of computerized physician order entry.

January 17, 2007

Health care-associated infections among critically ill children in the US, 2013-2018.

October 28, 2020

Heatwaves, hospitals and health system resilience in England: a qualitative assessment of frontline perspectives from the hot summer of 2019.

March 22, 2023

Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason's Swiss cheese model.

July 30, 2014

A public health approach to patient safety reporting systems is urgently needed.

June 8, 2011

Variation in electronic test results management and its implications for patient safety: a multisite investigation.

August 19, 2020

Risk from delayed or missed care and non-COVID-19 outcomes for older patients with chronic conditions during the pandemic.

June 8, 2022

Diagnostic error in pediatric cancer.

January 17, 2018

Opportunities to enhance laboratory professionals' role on the diagnostic team.

November 16, 2016

Content analysis of patient complaints.

October 29, 2008

An observational study of changes to long-term medication after admission to an intensive care unit.

December 6, 2006

Are opioid infusions used inappropriately at end of life? Results from a quality/safety project.

July 20, 2022

Association between end-of-rotation resident transition in care and mortality among hospitalized patients.

December 14, 2016

Stakeholder safety communication: patient and family reports on safety risks in hospitals.

October 12, 2022

Patient safety culture and the second victim phenomenon: connecting culture to staff distress in nurses.

August 10, 2016

The Second Victim Experience and Support Tool: validation of an organizational resource for assessing second victim effects and the quality of support resources.

October 22, 2014

Effect of prescriber notifications of patient’s fatal overdose on opioid prescribing at 4 to 12 months: a randomized clinical trial.

January 18, 2023

Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals.

October 10, 2012

Creating a fair and just culture: one institution's path toward organizational change.

October 10, 2007

Rural hospital nursing: better environments = shared vision and quality/safety engagement.

April 29, 2009

Risk factors for i.v. compounding errors when using an automated workflow management system.

July 27, 2016

ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis.

May 3, 2017

Clinical clerkship students' perceptions of (un)safe transitions for every patient.

May 14, 2014

Establishing an international baseline for medication safety in oncology: findings from the 2012 ISMP International Medication Safety Self Assessment for Oncology.

December 3, 2014

The effect of evidence in crisis learning: based on a perspective integration framework.

October 25, 2023

Nurses: the patient's first—and perhaps last—line of defense.

June 24, 2009

The impact of nursing skill-mix on adverse events in intensive care: a single centre cohort study.

May 31, 2023

Intersystem medical error discovery: a document analysis of ethical guidelines.

January 12, 2022

An evidence synthesis on perioperative handoffs: a call for balanced sociotechnical solutions.

April 5, 2023

An exploration of safety climate in nursing homes.

August 8, 2012

Ethical issues in patient safety research: a systematic review of the literature.

September 9, 2015

Discrepancies between prescribed and actual pediatric home parenteral nutrition solutions.

November 2, 2016

How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interventional study.

November 15, 2017

An overlooked condition.

November 30, 2005

When does quality improvement count as research? Human subject protection and theories of knowledge.

March 6, 2005

Missed diagnosis of cancer in primary care: insights from malpractice claims data.

August 7, 2019

The Healthcare Complaints Analysis Tool: development and reliability testing of a method for service monitoring and organisational learning.

February 24, 2016

Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety.

September 26, 2018

Online patient feedback as a safety valve: an automated language analysis of unnoticed and unresolved safety incidents.

September 14, 2022

Identifying and encouraging high-quality healthcare: an analysis of the content and aims of patient letters of compliment.

August 5, 2020

Stakeholders in safety: patient reports on unsafe clinical behaviors distinguish hospital mortality rates.

May 20, 2020

Guilty, afraid, and alone — struggling with medical error.

October 31, 2007

Impact of barcode medication administration technology on how nurses spend their time providing patient care.

January 7, 2009

Types, prevalence, and potential clinical significance of medication administration errors in assisted living.

June 4, 2008

Patient safety and medications in the home.

April 14, 2010

Describing the evidence linking interprofessional education interventions to improving the delivery of safe and effective patient care: a scoping review.

March 27, 2024

The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop.

December 21, 2016

Related Resources

Patient Safety Innovations

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

January 31, 2024

National Healthcare Quality and Disparities Reports.

January 9, 2024

Compliance with central line maintenance bundle and infection rates.

August 23, 2023

'We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death.

September 14, 2022

Algorithm that detects sepsis cut deaths by nearly 20 percent.

August 24, 2022

Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative.

May 18, 2022

Dying for Care.

March 30, 2022

Quality and safety in hospital pediatrics during COVID-19: a national qualitative study.

January 12, 2022

Patients went into the hospital for care. After testing positive there for Covid, some never came out.

November 17, 2021

A night in the hospital, from both ends of the stethoscope.

January 20, 2021

The plague year. The mistakes and the struggles behind America’s coronavirus tragedy.

January 13, 2021

Why false positives merit concern, too.

November 4, 2020

Catheter-associated urinary tract infection reduction in a pediatric safety engagement network.

September 30, 2020

Sent home to die.

September 16, 2020

When the misdiagnosis is child abuse.

September 2, 2020

How the pandemic defeated America.

August 19, 2020

Avoiding care during the pandemic could mean life or death.

August 12, 2020

Interprofessional/interdisciplinary teamwork during the early COVID-19 pandemic: experience from a children's hospital within an academic health center.

August 12, 2020

Coronavirus: can this California prison save itself from Covid-19?

August 5, 2020

As coronavirus ravaged nursing homes, inspectors were not being tested.

August 5, 2020

As college students return, a crisis in campus care awaits.

July 29, 2020

The U.S. is repeating its deadliest pandemic mistake.

July 22, 2020

Protecting children from iatrogenic harm during COVID19 pandemic.

July 15, 2020

'I'm smiling under here': Masks, plexiglass and questions the norm as hospitals lure patients back in COVID-19 era.

June 17, 2020

Dramatic drop in cancer diagnoses amid COVID pandemic is cause for concern, doctors say.

May 27, 2020

Nursing home workers warned government about safety violations before COVID-19 outbreaks and deaths.

May 27, 2020

Hospital workers complain of minimal disclosure after COVID exposures.

May 27, 2020

How the pandemic is reshaping hospital architecture and design.

May 20, 2020

Before mea culpa, Children’s was confident its air systems weren’t source of infection

December 11, 2019

Why your doctor's white coat can be a threat to your health.

May 8, 2019

See More About The Topic

Children's Hospital investigated five patient deaths from deadly fungal disease in 2009.

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Children's Hospital investigated five patient deaths from deadly fungal disease in 2009.

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site