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(Context note: I started writing this as a top-level comment, but I think it ultimately fits better as a concurring reply here.)

For all of the galling failures described in this story, I see it first and foremost as an indictment of the (non-)system. If a plane has a rough landing that results in so much as a sprained ankle, we expect everyone involved with that flight to be up to their eyeballs in an NTSB investigation that will produce a thorough and authoritative account of the failure. Alaska Airlines Flight 1282 (aka the 737 Max door plug blowout) officially resulted in 3 minor injuries, and that was a massive scandal that prompted a tidal wave of scrutiny against Boeing and perhaps a dozen high-profile pieces about how its engineering culture was undermined by McDonnell Douglas's management culture. At least as many people have evidently been fatally poisoned at St. Peter's.

But we apparently can't investigate medical failures with even a modest fraction of that level of robustness because... uh... reasons. The knee-jerk deflection is that medicine is messy and doctors are due a certain amount of deference for judgment calls in the context of the situation; are the same points not also true of aviation and pilots? Suppose that Dr. Wiener is entitled to walk away a free man because of a non-blame-oriented culture of dispassionate root cause analysis. In that case, we're due (and he's due, for that matter) a very detailed and public accounting of exactly where the failures occurred, whether they're his or others'. But maybe we're just not ready to look this shit in the eye.

(I'm also making a note to myself to double my usual donation to ProPublica this year; they've been kicking ass at the sort of muckraking that we haven't seen nearly enough of in the past 15-20 years)