Commentary: The Maisano Case at Zurich University Hospital Shockingly Reveals the Dangers of a Poor Error Culture

The shocking revelations from Zurich University Hospital's cardiac surgery department serve as a stark, painful reminder of how a dysfunctional error culture can have fatal consequences. The findings, detailing severe treatment quality issues between 2014 and 2020, indicate that approximately seventy more patients died than statistically expected. This is not merely a case of unfortunate outcomes; it points to systemic failures that allowed such a situation to persist for years.

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The cardiac medicine is in the public eye since it became clear that there were serious deficiencies at the University Hospital.

What is particularly disturbing is the alleged use of novel implants, some co-developed by the clinic's director, Francesco Maisano, who also stood to profit financially from their success. These implants offered dubious benefits and were sometimes used inappropriately. This raises serious ethical questions about patient welfare versus financial interests, a conflict that should be unthinkable in a medical setting.

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Imagine if at a Swiss airline there was a group of pilots around a guru-like revered captain who repeatedly endangered safety with daring flight maneuvers. And not only that: they would crash-land, injuring and killing passengers. They would test novel flight instruments that, from their own perspective, were supposed to make flying safer, but had the opposite effect – instruments that they partly developed themselves and that at least the captain profited from. And all of that had been covered up for years.

The comparison drawn to the aviation industry is apt. In aviation, a robust error culture, where mistakes are openly reported, analyzed, and learned from, is paramount to safety. Pilots have a vested interest in safety, as they are in the plane with their passengers. The Zurich case, however, suggests a culture where errors were potentially concealed or inadequately addressed, leading to tragic, preventable deaths. The hospital's eventual reporting of 24 cases to the prosecutor's office is a necessary step, but it underscores the long road to rebuilding trust.

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An investigation report has shown that there were serious deficiencies in the cardiac surgery department of the Zurich University Hospital between 2014 and 2020. According to expert calculations, around seventy more people died due to poor treatment quality than would have been statistically expected.

This incident compels us to ask how such a situation could unfold and continue unchecked within a respected Swiss institution. While the NZZ, as a publication committed to rigorous analysis, will continue to scrutinize these events, the fundamental lesson is clear: medicine must learn from the best practices in other high-risk fields. A culture that embraces learning from mistakes, rather than hiding them, is not just a management trend; it is a life-saving necessity.

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The whole of Switzerland is asking itself: How can something like this happen and continue for years? In aviation, that would simply be impossible.