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/

https://www.virginiamasoninstitute.org/2014/03/terrible-tragedy-and-powerful-legacy-of-preventable-death/

Charlene Murphy, 2017, Vanderbilt, TN

MRI

Vercuronium given instead of Versed for sedation

https://www.tennessean.com/story/news/health/2019/03/27/radonda-vaught-vanderbilt-nurse-homicide-trial-vecuronium-versed/3216750002/

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

http://www.nytimes.com/1992/11/12/nyregion/when-medicine-errs-special-report-roosevelt-hospital-3-deaths-lead-3-different.html?pagewanted=all&mcubz=0

Caroline Carcerano, 74 yo, 2014, Tufts, MA

Intrathecal ionic contrast substituted for nonionic contrast (Could have been in Radiology)

https://www.bostonglobe.com/lifestyle/health-wellness/2014/08/30/surgical-error-tufts-medical-center-prompts-widespread-changes-operating-rooms/8JFgKrx6FIvLLT6Uja2bkJ/story.html

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://practicalneurology.com/articles/2015-jan-feb/expert-opinion-streptococcal-meningismus-after-ct-myelography-in-a-patient-with-hiv

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/