Neuroradiology Horror Stories
This is a companion website for my SanDiego Radiology Society talk on Nov 3, 2020
Forgive and Remember 2nd Edition (2003) - Charles Bosk
This is the reference for the "horror story" method of teaching.
On its initial publication, Forgive and Remember emerged as the definitive study of the training and lives of young surgeons. Now with an extensive new preface, epilogue, and appendix by the author, reflecting on the changes that have taken place since the book's original publication, this updated second edition of Charles L. Bosk's classic study is as timely as ever.
http://www.amazon.com/Forgive-Remember-Managing-Medical-Failure/dp/0226066789
(I reviewed the first edition (1979) as a college student, before they invented systems based practice (see below))
These are the cases we will discuss:
Mary McClinton, age 69, 2004, Virginia Mason, WA
Neuro angio
Intraarterial chlorhexidine injected instead of contrast.
http://www.medscape.com/viewarticle/497765
http://www.seattletimes.com/seattle-news/suit-filed-over-virginia-mason-medical-centers-error/
Charlene Murphy, 2017, Vanderbilt, TN
MRI
Vercuronium given instead of Versed for sedation
Lillian Cedeno, 1985, Albany Medical Center, NY
Intrathecal chemo with Vincristine instead of methotrexate? (Could have been a flouro guided LP.)
https://www.nytimes.com/1985/04/14/nyregion/hospital-faulted-for-drug-mistake.html
Joseph Brinson, 1992, Roosevelt Hospital (Mount Sinai West), NY
Pulse ox alarmed and was ignored
Caroline Carcerano, 74 yo, 2014, Tufts, MA
Intrathecal ionic contrast substituted for nonionic contrast (Could have been in Radiology)
Michael Colombini, 2001, Westchester Medical Center, NY
MRI
Oxygen cylinder killed patient.
https://www.nytimes.com/2001/08/01/nyregion/small-town-reels-from-boy-s-mri-death.html
43 yo
Meningitis after myelography (without a mask)
https://www.jacr.org/article/S1546-1440(11)00554-0/pdf
Stone Chest
Complication of fentanyl 100 mcg 25, 25, 50
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5349614/