Presentation
Exploring Journey Mapping: A Systems Approach to Investigating the Largest Cluster of Fungal Meningitis Outbreaks through Patients’ Eyes
DescriptionBackground. In November 2022, Fusarium solani meningitis was first reported in Durango, Mexico. Over the following months, this outbreak grew into the largest recorded cluster of fungal meningitis worldwide, resulting in 81 confirmed cases and 42 deaths. With a fatality rate of nearly fifty percent, the outbreak left many otherwise healthy postpartum women critically ill or dead after receiving neuraxial anesthesia as part of their maternity care. In May 2023, a second fungal meningitis outbreak in the Mexican city of Matamoros, more than six hundred miles from Durango, resulted in 34 confirmed cases and 12 fatalities. Neuraxial anesthesia is widely used in perioperative and obstetric care, offering safe pain management when performed under proper aseptic conditions.
Taken together, these outbreaks demonstrate that unsafe care is not random, but the predictable consequence of systemic vulnerabilities. This study investigates the fungal meningitis outbreaks in Mexico and provides a unique lens through which to examine how human factors and systems ergonomics intersect with healthcare practices and outcomes. These events illustrate how fragile infrastructures, regulatory gaps, and limited resources can transform a routine medical procedure into a catastrophic public health failure.
The purpose of this study is to highlight patient lived experiences and analyze how systemic failures created conditions for widespread patient harm. Patient interviews and journey mapping based on those interviews provided a powerful method for understanding the fungal meningitis outbreaks. By centering survivor perspectives, this project underscores the essential role patients can play as critical collaborators in safety investigations. Incorporating human factors principles into healthcare system design can transform individual tragedies into global lessons for safer practices.
Methods. We conducted four semi-structured interviews with survivors of the Durango outbreak (four of the 39 who survived). Using interview data, we created individual journey maps—visual tools that diagrammatically represent experiences by theme, function, and chronology [1]—to systematically capture and organize patient narratives. These maps documented experiences from initial admission through discharge and any subsequent readmissions or treatments for complications. IRB approval was obtained from California State University, Northridge (IRB-FY24-446).
Results. The journey maps illustrate the intersections and interrelationships between healthcare organizations and patients, presenting survivors’ experiences chronologically and holistically. These maps reveal how patients interpret and respond to system failures, draw parallels between their experiences, and identify shared observations and risk factors across cases and hospitals - patterns often invisible to clinicians or administrators. In this study, the four developed journey maps based on the discussed patient interviews were analyzed, and they were compared with each other as well.
Survivors described multiple lapses in sterile technique, including unsealed or exposed medical instruments, and minimal use of personal protective equipment, such as gloves and face masks. Once symptoms began, patients experienced delays in isolation, poor communication from healthcare providers, and limited transparency regarding diagnoses and treatments. Many were denied access to their medical records or received incomplete explanations about their conditions and care.
Case study. The experience of one woman, Patient A, illustrates the devastating consequences of these systemic failures. She underwent a cesarean section in September 2022 at a private hospital in Durango, seeking private care to avoid the negligence previously experienced by her family in the public system. Her experience, however, soon revealed significant irregularities.
The patient recalled an unusual double-prick sensation during neuraxial anesthesia placement, that caused severe pain. Staffing shortages during recovery left her without adequate support. The recovery room was overheated, and her infant developed a rash, yet nurses dismissed her concerns. Within days, she developed severe headaches, neck stiffness, fever, and chest pain – classic symptoms of meningitis.
Despite clear indications of meningitis, her doctors repeatedly misdiagnosed her. She was told her symptoms were psychological and was prescribed antidepressants. Even when evaluated by a neurosurgeon, meningitis was never discussed, despite the physician treating similar cases. For more than two months, her illness remained unexplained. She learned of the outbreak only through news reports of meningitis-related deaths. A lumbar puncture ultimately confirmed fungal meningitis.
This case illustrates communication breakdowns, cognitive biases, and systemic inefficiencies that prolonged her suffering and endangered her life. Her experience reflects a pattern across the four interviews: patients recognized that something was gravely wrong, yet their concerns were minimized until public reporting forced providers to acknowledge the true nature of the outbreak.
Analysis. The interviews and journey maps produced several consistent themes. Patients endured prolonged delays before receiving accurate diagnoses, even as their symptoms worsened. Provider communication was inconsistent, leaving survivors to learn critical information from news outlets or other patients instead of their clinicians. Many patients were denied access to their medical records. Environmental hazards, such as overheated recovery rooms or inadequate instrument sterilization, were common. The psychological toll was profound: survivors described feeling dismissed, isolated, frightened, and unable to care for their newborns.
Socio-economic conditions further amplified vulnerability. Limited trust in public hospitals drove many patients to private facilities, which often lacked resources or oversight needed to ensure rigorous safety protocols. Broader inequalities in healthcare access left patients with few alternatives once complications arose. The outbreaks demonstrate how systemic fragility and economic disparities create conditions in which preventable harm becomes inevitable.
The fungal meningitis outbreaks did not arrive from isolated clinical errors, but emerged from systemic failures across multiple levels of the healthcare system. At the provider level, unsafe practices such as vial sharing and syringe reuse were common [2]. At the organizational level, policies regarding drug handling and sterilization were either absent or unenforced [2]. At the regulatory level, oversight was fragmented, with no agency clearly accountable for ensuring compliance with safety standards [2].
In summary, the patient journey mapping provided a comprehensive method for understanding how specific procedural failures contributed to the outbreaks and for analyzing patient experiences in a systematic way. The findings show that patients often possess the clearest view of systemic risks. Treating patients as stakeholders can enable earlier hazards identification and more effective responses [3]. Patient voices are not supplementary but central to understanding how healthcare failures unfold.
Although this outbreak was concentrated in Mexico, its lessons are globally relevant. Neuraxial anesthesia is a standard practice worldwide, and failures in sterile technique have caused similar outbreaks elsewhere. Mexico’s systemic responses, such as redesigning morphine vials into single-use one-milliliter doses and restricting narcotic transport between hospitals, provide examples of system’s redesign that can be adapted internationally. National campaigns to reinforce sterile handling and improve clinician awareness highlight the importance of policy-level interventions.
Finally, the outbreak emphasizes the need for hospitals to strengthen sterile techniques and relevant trainings and to establish transparent systems that allow patients timely access to their medical records. Furthermore, there is a need to ensure that regulatory bodies and hospitals are held accountable for compliance. Human factors research can guide these efforts by demonstrating how small design flaws or communication gaps, when magnified by systemic weaknesses, can lead to large-scale harm. It is essential that we coproduce care with patients to design healthcare services, and to learn from errors [4].
References
[1] Joseph AL, et al. Exploring Patient Journey Mapping and the Learning Health System: Scoping Review. JMIR Hum Factors. 2023;10: e43966.
[2] Tabibzadeh, et al. Systematic Root Cause Investigation of Fungal Meningitis Outbreaks Associated with Procedures Performed under Neuraxial Anesthesia in Mexico, International Symposium on HFE in Health Care, Chicago, IL, March 24–27, 2024.
[3] Giardina TD, et al. Learning from Patients’ Experiences Related to Diagnostic Errors Is Essential for Progress in Patient Safety. Health Aff (Millwood). 2018;37(11):1821-1827.
[4] Batalden M, et al. Coproduction of healthcare service. BMJ Qual Saf. 2016;25(7):509-17.
Taken together, these outbreaks demonstrate that unsafe care is not random, but the predictable consequence of systemic vulnerabilities. This study investigates the fungal meningitis outbreaks in Mexico and provides a unique lens through which to examine how human factors and systems ergonomics intersect with healthcare practices and outcomes. These events illustrate how fragile infrastructures, regulatory gaps, and limited resources can transform a routine medical procedure into a catastrophic public health failure.
The purpose of this study is to highlight patient lived experiences and analyze how systemic failures created conditions for widespread patient harm. Patient interviews and journey mapping based on those interviews provided a powerful method for understanding the fungal meningitis outbreaks. By centering survivor perspectives, this project underscores the essential role patients can play as critical collaborators in safety investigations. Incorporating human factors principles into healthcare system design can transform individual tragedies into global lessons for safer practices.
Methods. We conducted four semi-structured interviews with survivors of the Durango outbreak (four of the 39 who survived). Using interview data, we created individual journey maps—visual tools that diagrammatically represent experiences by theme, function, and chronology [1]—to systematically capture and organize patient narratives. These maps documented experiences from initial admission through discharge and any subsequent readmissions or treatments for complications. IRB approval was obtained from California State University, Northridge (IRB-FY24-446).
Results. The journey maps illustrate the intersections and interrelationships between healthcare organizations and patients, presenting survivors’ experiences chronologically and holistically. These maps reveal how patients interpret and respond to system failures, draw parallels between their experiences, and identify shared observations and risk factors across cases and hospitals - patterns often invisible to clinicians or administrators. In this study, the four developed journey maps based on the discussed patient interviews were analyzed, and they were compared with each other as well.
Survivors described multiple lapses in sterile technique, including unsealed or exposed medical instruments, and minimal use of personal protective equipment, such as gloves and face masks. Once symptoms began, patients experienced delays in isolation, poor communication from healthcare providers, and limited transparency regarding diagnoses and treatments. Many were denied access to their medical records or received incomplete explanations about their conditions and care.
Case study. The experience of one woman, Patient A, illustrates the devastating consequences of these systemic failures. She underwent a cesarean section in September 2022 at a private hospital in Durango, seeking private care to avoid the negligence previously experienced by her family in the public system. Her experience, however, soon revealed significant irregularities.
The patient recalled an unusual double-prick sensation during neuraxial anesthesia placement, that caused severe pain. Staffing shortages during recovery left her without adequate support. The recovery room was overheated, and her infant developed a rash, yet nurses dismissed her concerns. Within days, she developed severe headaches, neck stiffness, fever, and chest pain – classic symptoms of meningitis.
Despite clear indications of meningitis, her doctors repeatedly misdiagnosed her. She was told her symptoms were psychological and was prescribed antidepressants. Even when evaluated by a neurosurgeon, meningitis was never discussed, despite the physician treating similar cases. For more than two months, her illness remained unexplained. She learned of the outbreak only through news reports of meningitis-related deaths. A lumbar puncture ultimately confirmed fungal meningitis.
This case illustrates communication breakdowns, cognitive biases, and systemic inefficiencies that prolonged her suffering and endangered her life. Her experience reflects a pattern across the four interviews: patients recognized that something was gravely wrong, yet their concerns were minimized until public reporting forced providers to acknowledge the true nature of the outbreak.
Analysis. The interviews and journey maps produced several consistent themes. Patients endured prolonged delays before receiving accurate diagnoses, even as their symptoms worsened. Provider communication was inconsistent, leaving survivors to learn critical information from news outlets or other patients instead of their clinicians. Many patients were denied access to their medical records. Environmental hazards, such as overheated recovery rooms or inadequate instrument sterilization, were common. The psychological toll was profound: survivors described feeling dismissed, isolated, frightened, and unable to care for their newborns.
Socio-economic conditions further amplified vulnerability. Limited trust in public hospitals drove many patients to private facilities, which often lacked resources or oversight needed to ensure rigorous safety protocols. Broader inequalities in healthcare access left patients with few alternatives once complications arose. The outbreaks demonstrate how systemic fragility and economic disparities create conditions in which preventable harm becomes inevitable.
The fungal meningitis outbreaks did not arrive from isolated clinical errors, but emerged from systemic failures across multiple levels of the healthcare system. At the provider level, unsafe practices such as vial sharing and syringe reuse were common [2]. At the organizational level, policies regarding drug handling and sterilization were either absent or unenforced [2]. At the regulatory level, oversight was fragmented, with no agency clearly accountable for ensuring compliance with safety standards [2].
In summary, the patient journey mapping provided a comprehensive method for understanding how specific procedural failures contributed to the outbreaks and for analyzing patient experiences in a systematic way. The findings show that patients often possess the clearest view of systemic risks. Treating patients as stakeholders can enable earlier hazards identification and more effective responses [3]. Patient voices are not supplementary but central to understanding how healthcare failures unfold.
Although this outbreak was concentrated in Mexico, its lessons are globally relevant. Neuraxial anesthesia is a standard practice worldwide, and failures in sterile technique have caused similar outbreaks elsewhere. Mexico’s systemic responses, such as redesigning morphine vials into single-use one-milliliter doses and restricting narcotic transport between hospitals, provide examples of system’s redesign that can be adapted internationally. National campaigns to reinforce sterile handling and improve clinician awareness highlight the importance of policy-level interventions.
Finally, the outbreak emphasizes the need for hospitals to strengthen sterile techniques and relevant trainings and to establish transparent systems that allow patients timely access to their medical records. Furthermore, there is a need to ensure that regulatory bodies and hospitals are held accountable for compliance. Human factors research can guide these efforts by demonstrating how small design flaws or communication gaps, when magnified by systemic weaknesses, can lead to large-scale harm. It is essential that we coproduce care with patients to design healthcare services, and to learn from errors [4].
References
[1] Joseph AL, et al. Exploring Patient Journey Mapping and the Learning Health System: Scoping Review. JMIR Hum Factors. 2023;10: e43966.
[2] Tabibzadeh, et al. Systematic Root Cause Investigation of Fungal Meningitis Outbreaks Associated with Procedures Performed under Neuraxial Anesthesia in Mexico, International Symposium on HFE in Health Care, Chicago, IL, March 24–27, 2024.
[3] Giardina TD, et al. Learning from Patients’ Experiences Related to Diagnostic Errors Is Essential for Progress in Patient Safety. Health Aff (Millwood). 2018;37(11):1821-1827.
[4] Batalden M, et al. Coproduction of healthcare service. BMJ Qual Saf. 2016;25(7):509-17.
Authors
Event Type
Oral Presentations
TimeMonday, March 2311:37am - 12:00pm EDT
LocationMurray Hill East
Patient Safety Research and Initiatives