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