The moment the cannula infiltrated, time split in two. In one world, I was an American pediatric emergency medicine physician. In the other, I was Leela’s mother, holding my 11-month-old daughter in a Scottish resuscitation bay as she writhed and screamed, the flesh of her foot burning from the inside. I had tried to prevent this. We had moved from New York City to Edinburgh three weeks earlier. When Leela developed a prolonged febrile seizure — a common fever-related seizure in young children — we took her to the emergency department. The seizure persisted despite initial treatment, and the medical team prepared to administer an anti-epileptic medication called phenytoin. This alarmed me. Pediatricians learn early in training that phenytoin is highly toxic to tissue if it leaks from an IV — a complication known as an extravasation injury that can cause severe tissue necrosis and, in rare cases, limb loss. The risk is particularly concerning in infants and during active seizures, when IV access can be difficult to maintain. I explained gently, then more firmly, that in the United States, fosphenytoin is preferred by nearly all pediatric emergency departments for status epilepticus because it is safer. I wasn’t trying to interfere; I wanted to trust the team caring for my daughter. This was a prolonged febrile seizure in an otherwise healthy child at a tertiary children’s hospital. It was routine. The irony was sharp. In the resuscitation bay, I felt oddly at home for the first time in weeks — except now I was the parent of the child whose care I would normally direct, and I was powerless. The infusion proceeded according to protocol. I reminded myself that I was her mother, not her doctor. Three hours later, when the team recognized the severity of the extravasation injury, professional awareness gave way to primal helplessness. I knew what could happen before it happened — and I couldn’t stop it. Before this experience, I was one of many American physicians who looked longingly at universal health care systems abroad. As the U.S. grappled with growing political threats to science, public health, evidence-based medicine, and the health care safety net, I wondered whether the future of ethical medical practice lay elsewhere. Practicing in the U.S. also meant navigating a system shaped by litigation fears, consumer expectations, and business pressures that complicate clinical decision-making. From a distance, other systems appeared more humane, more rational — a refuge from our own frustrations. Living and practicing medicine outside the United States complicated that belief. In the days following Leela’s injury, I waited for the part of the story I knew best from my professional life: acknowledgment, transparency, and learning. I have always believed the measure of a health care system is not whether harm occurs, but how it responds when it does. Errors are inevitable, even in excellent hospitals. I have made many. What matters is whether they become opportunities to learn or threats to manage. That moment never came. I repeatedly asked to speak with my daughter’s medical team. They eventually apologized and said an adverse event review would be filed. At discharge, we were promised discussion and follow-up. We heard nothing. When I filed a formal complaint, I hoped the silence reflected the overwhelmed, understaffed, and poorly coordinated system we encountered during our admission rather than avoidance. Leela suffered through emergent surgery, agonizing dressing changes, and faced a guarded prognosis for weeks. I provided clinical context and supporting literature and asked a simple question: What will you change so another child isn’t injured like this? A month later, the answer arrived: nothing. I was told protocol had been followed, that phenytoin was within guidelines, that these things “sometimes happen.” The injury — raw, oozing, angry — had turned our lives upside down, but it was rendered invisible in the institutional review. Not because the harm wasn’t serious or preventable, but because the steps on the page had been followed. In the system’s logic, nothing had gone wrong. Something had gone wrong. Each moment held clues — pump alarms, repeated IV adjustments, uncertainty about whether she was still seizing, a tightly wrapped foot trembling as a vesicant infused. Each was an opportunity to ask whether safeguards were sufficient. I offered to be a partner in that learning. Silence followed. Leela’s injury demanded months of intensive care: twice-daily dressing changes, sedated imaging, repeated emergency visits, and consultations across specialties. Two skin grafts and three weeks in the hospital attached to a wound VAC device were recommended to prevent severe infection. A multidisciplinary meeting was scheduled to discuss next steps. When we arrived, no clinicians came. We returned to New York to seek care. Conservative, evidence-based management was recommended, and over eight months the wound slowly closed. I believe deeply in universal health care. But universal care also must mean universal safety and accountability, not merely universal access. My experience forced me to confront an uncomfortable truth: Average outcomes can obscure major differences in safety culture. The American system contains profound inequities, yet many settings maintain extraordinarily high standards of care shaped by privilege, geography, and institutional resources. These expectations — though costly and perhaps unsustainable — foster a culture of relentless scrutiny that is critical to patient safety across much of American medicine. In the U.S. academic medical centers where I worked, problems were expected to be owned, questioned, and solved in a timely manner even when resources were strained — not quietly accepted. Harm was treated as data. Only after practicing within a system where staffing limits, formulary constraints, and service gaps are often normalized rather than interrogated did I grasp how much that culture mattered. More surprising than the shortcomings themselves is how rarely they are openly acknowledged or questioned by either patients or providers. In American medicine, moral injury often means fighting to improve a system that falls short. Here, the injury is watching its substandard limits quietly accepted — and learning how difficult they are to challenge or improve. Practicing in both systems reshaped my sense of baseline pediatric care. I remain troubled that uninsured children in the United States can lack preventive care. Yet working in the U.K., where pediatric care is largely reactive and specialist access can take years, underscored something I had not expected: Routine well-child visits, timely subspecialty care, and clear clinical ownership of a child’s overall health are not universal standards. Protocols are designed for populations but carried by individuals. When treated as rules rather than tools for judgment, a system can function perfectly on paper while failing the person in front of it. Different systems create accountability in different ways. In the U.S., regulatory and legal pressures can distort responses toward liability rather than learning. Yet they also create urgency and visibility: The threat of reputational damage and financial loss can drive rapid change. Systems that rely primarily on internal review may support learning in theory. However, when transparency and external scrutiny are limited — and consequences are largely intangible — preventable injuries risk becoming normalized rather than examined. Ironically, some of the forces I struggled with in American medicine —regulatory scrutiny, legal risk, and relentless expectations for performance— also help sustain this culture of constant examination. I think about the compassionate clinicians who cared for my daughter. I do not blame them. I’m deeply grateful for their care. They worked within the policies and constraints they were given. But clinicians cannot improve systems alone; institutions must be willing to examine harm openly and change course when needed. I think about formulary decisions. Fosphenytoin — the safer alternative used in most U.S. emergency departments — is not universally stocked in the U.K. because of cost. These trade-offs achieve savings, but the risks of preventable harm are often borne by the most vulnerable patients. When harm remains unrecognized as error, safeguards rarely follow. I think about families without the training to question what happened or the resources to seek care elsewhere — families navigating systems where decisions are often delivered rather than discussed. I wonder whether that norm explains why my concern surprised the clinicians caring for my daughter. When questioning is uncommon, early warnings are easy to overlook. The waiting rooms of the wound care and plastic surgery clinics we visited weekly held other children with extravasation injuries. I do not know whether these events were reviewed collectively or whether patterns were identified. When harm is assessed in isolation rather than in aggregate, systemic risk can remain hidden. I navigated the hospital complaint process and escalated to the national ombudsman. For more than a year, the case remained unresolved. Recently, I received a letter stating that my daughter’s injury had prompted internal review and reflection. Yet despite gaps in documentation and lingering uncertainty about key aspects of what happened, the conclusion remained unchanged: Protocol had been followed, and no error was recognized. If an injury of this severity cannot be recognized as a serious error, what does accountability mean? Every health care system has trade-offs. But any system that cannot acknowledge harm cannot learn from it — and systems that fail to learn will harm again. I do not want punishment or blame. What I want is learning. I want systems capable of saying: This happened. It should not have. Here is what we are changing. I want clinicians to feel safe questioning protocols. I want families to be treated as partners in safety rather than problems to be managed. Transparency should be a reflex, not an aspiration. My daughter is healing. Her foot bears a large scar, and she wears a brace most of the day — a reminder of how close we came to a far worse outcome. She is joyful and blissfully unaware of the meaning her injury holds for me. But I carry it — the knowledge that harm will continue unless our response to harm changes. In some systems, the greatest danger is not the mistake itself, but the unwillingness to learn. Nisha Narayanan, M.D., is a clinical assistant professor of pediatrics (voluntary) at Weill Cornell Medicine and practices both in New York City and in Edinburgh, Scotland.
