Serratia liquefaciens Infections at a Hemodialysis Center

To the Editor: Dr. Grohskopf and her colleagues (May 17 issue) 1 and the editorialist who commented on their study of Serratia liquefaciens infections at a hemodialysis center 2 missed an opportunity to evaluate the errors in the system that contributed to this “near miss.” The Institute of Medicine report 3 on the epidemiology of error in medicine shows us the importance of looking for root causes. The authors and editorialist enumerate the human errors or proximate causes that led to the adverse event. There are also remote causes or latent errors that are beyond the control of the health care workers. Training . . .