Learning from Mistakes

In the present issue of the Journal, Patrick and his colleagues (pages 330-336) describe an episode in the summer of 2003, immediately following the severe acute respiratory syndrome (SARS) epidemic, when an outbreak of respiratory illness occurred in a long-term care facility in Vancouver, and was initially reported by the National Microbiology Laboratory (NML) to be SARS. The local laboratories did not support the diagnosis and, subsequently, the NML diagnosis was acknowledged to be incorrect. The misdiagnosis, however, had an immediate negative impact by suggesting that SARS continued to be transmitted in Canada, raising the spectre of social and economic impacts recently experienced by Toronto. The episode also had a longer term negative impact on national and international perceptions of the reliability of the Canadian laboratory. Thus, a critical review of this episode to understand what happened and to avoid future errors is appropriate. Dr Patrick and his coauthors, including those from the NML, are to be congratulated for presenting this information to the Canadian infectious diseases and public health communities