Lucian Leape’s legacy for patient safety

“Errors must be accepted as evidence of systems flaws, not character flaws.”—Lucian Leape1 In losing Lucian Leape to heart failure last 30 June, at the age of 94 years, we lost a rare physician whose insights fundamentally changed how clinicians and the public understand the practice of medicine. His contributions helped transform medicine’s moral self-conception from one that prized perfection and regarded error as a character failure to one that prizes humility and understanding failure. Medical mistakes were his laboratory. They were both his subject and his inspiration. And his career was a study in audacity and late blooming. He was born on 7 November 1930, in Bellevue, Pennsylvania. His father worked for a steel company. His mother was a schoolteacher. He studied chemistry at Cornell, where he met his wife, Marty. He served in the US Navy, then went to Harvard Medical School, graduating in 1959. He completed general and thoracic surgery residency at Massachusetts General Hospital, then a paediatric surgery fellowship at Boston Children’s Hospital. His first appointment was at the University of Kansas. He helped found the American Pediatric Surgery Association in 1970. He returned to Boston in 1973 as Chief of Pediatric Surgery at Tufts Medical Center. He had a steady research output, writing just under half of his 200 academic papers and book contributions during his surgical career. He published findings on subjects from child burn treatment to nutritional deficiencies like rickets to paediatric reflux disease. Paediatric surgery was a new speciality, and he was among the pioneers inventing the field as they practised. Several of his papers also show interest in safety from the start. One of his first papers, in 1967, on 148 cases of testicular torsion, was entitled, ‘Invitation to Error’.2 He reported an adverse event in a child who …