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According to a new paper, one of neuroscience’s most famous case-studies came about as a result of a serious medical blunder.
Henry Molaison (1926 – 2008), better known as HM, was an American man who developed a dramatic form of amnesia after receiving surgery that removed part of the temporal lobes of his brain.
According to Francois Mauguiere and Suzanne Corkin, the authors of the new paper, the whole thing was a mistake. Regarding HM’s diagnosis, Mauguiere and Corkin argue that HM almost certainly suffered from idiopathic generalized epilepsy (IGE).
If Mauguiere and Corkin are right, the tissue that was removed from HM’s temporal lobes was perfectly healthy. Who knows if neurosurgeons may even carry out selective rhinencephalic ablations in order to raise the threshold for all convulsions, and thus dispense with pharmaceutical anticonvulsants? The answer to your 2nd question is given above: the surgeon pursued his idea that the planned surgery would help ANY case of epilepsy, hence no further search for a focus was performed. This represents a large drop in the rate of seizures, but HM was still epileptic and still had an abnormal EEG. But, I think it’s not so much the God Complex (though that can surely be a problem) but corruption and management, especially with guidelines. Neuroskeptic is a British neuroscientist who takes a skeptical look at his own field, and beyond. About C101CANCER101's mission is to empower cancer patients and their caregivers to take control over their diagnoses and engage them as active partners in their care, by arming them with a toolkit to navigate their cancer journey.
1.3 million people have injuries that result from medication errors annually in the United States. A study recently published in Pediatrics found that one American child was given the wrong medication every eight minutes, although many of these errors were caregiver errors.
A definition of medication error is “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Medications that are associated more commonly with death or severe adverse drug events are those medications that involve the central nervous system, the cardiovascular system, or cancer chemotherapy drugs. The black box warning system that was established by the FDA in 1995 alerts doctors to the increased risks that are associated with some drugs. In my own family, my father was discharged from the hospital with a prescription for a medication that would have caused a fatal drug interaction with another medication he had been taking for a long time. Anyone who begins a new prescription should understand the drug and its effects, and any interactions with other medications they are taking. Prescription drug abuse is an epidemic in the United States, and sometimes a physician may be negligent by prescribing a dangerous drug to a patient at risk. One problem arises when a doctor prescribes a narcotic to a patient who may be dependent upon narcotics or may be abusing them. Overdose death drugs rise yearly, and in 2010, 38,329 people died of drug doses in this country, according to the US Center for Disease Control’s National Center for Health Statistics. Prescription drug overdoses are usually unintentional, with 74% of prescription drug overdoses resulting from accidental ingestion. Although hospitals and pharmacies have tightened restrictions on prescribing, it is still relatively simple for many people to obtain a large supply of painkillers or anti-anxiety drugs like Xanax or Ativan.
Although the FDA requires the manufacturers of opioid drugs, like Vicodin or Oxycontin, to provide education for doctors, their track record is poor.
Plaintiffs have been successful in lawsuits against physicians who have prescribed dangerous drugs irresponsibly. Doctors who are specialists in pain management should be especially careful, as they are often responsible for the prescription of powerful and addictive drugs over an extended period of time. If you or a family member has suffered as a result of negligent prescribing practices by your doctor, you may have legal recourse. Many nursing homes under-employ staff with the experience and ability to administer medications correctly.
If your loved one in a nursing home has suffered a serious injury or death as a result of neglect or outright reckless conduct, call Passen Law Group at 312-527-4500. Among the most common drugs involved in medication errors are blood thinners and antihypoglycemic medications prescribed for diabetes.
A recent study  found that warfarin (Coumadin), oral anti-platelet medications (Plavix, aspirin), insulin and medications like metformin or glipizide.
Sometimes equipment malfunctions, and large doses of drugs that should be administered over a long time period are delivered too rapidly. Morphine and other uploads are stacked together in a locked cabinet, with similar packaging, contributing to errors. Acetaminophen causes multiple problems, due to its various strengths and measuring devises for dispensing it.
With antibiotics, liquid concentrations cause confusion, especially over the measurement m: and the teaspoon. System errors include inadequate staffing, handwritten orders, and doses with trailing zeros or ambiguous labeling. If you or a loved one has been the victim of a medication error, you should see an attorney who specializes in medical malpractice. Another recent peer-reviewed study by Accredo Health Group and several university hospitals highlights how the wrong medication and other administration errors can be life-threatening. To speak with a top Chicago medical malpractice lawyer, call Passen Law Group at (312) 527-4500 for a free consultation. Medical errors are mistakes that can happen with medicine, surgery, tests, and other parts of your health care.
Illness can spread in hospitals when health care workers do not wash their hands or wear gloves. Ask your surgeon to make a mark with a pen before the surgery on the part of your body where the surgery will happen. To learn more about medical errors, call the AHRQ Publications Clearinghouse 1-800-358-9295 or go to the AHRQ Web sites section on Medical Errors.
Keywords: Medical error, fatal, causes of death, top ten, death, dying, end-of-life planning.
I have been attuned to medical error issues ever since my parents’ terminal hospitalizations in 2004 and 2005 — first my mother’s, after 3 weeks of intubation in a callously-run ICU, then my father’s fifteen months later for elective pacemaker eligibility testing that devolved to a fatal hospital-acquired MRSA infection. I’m less interested in the data per se than I am in its potential utility for end-of-life planning by families with a declining or terminal loved one who need to assess risk.
It’s past time for medical error to appear in “top ten” charts and also to acknowledge it during public end of life discussions that often are citizens’ first exposure to providers offering end-of-life guidance. How are we to know how many medical error deaths should be added independent of other categories of dying, and how many need to be included in death statistics that compound inaccurate analysis by being attributed to other causes? We hadn’t gotten close enough to the time of surgery to have been presented with a surgical release form (which, I’m told, would have stipulated the suspension of Dad’s Do Not Resuscitate (DNR) order). I felt hollow upon learning about these aspects of life support and resuscitation matters so long after Dad died; all of this ought to have been introduced to us at the time. I vowed to get to the bottom of all the failures, medicine’s and our own, and to share my findings. That fall I associated medical error with a top ten causes chart for the first time, in a metaphorical manner, by adding a picture of a jumbo jet atop the causes stack plus a legend explaining what it signified.
Wondering how to assess the numbers and present medical error deaths scaled to a chart, the best one can credibly do is float a proportionally sized box and footnote its limitations. I can’t integrate the error value into the original chart data (can anyone reading this do so?), although we know of and can further deduce some number of medical error deaths erroneously recorded as due to disease (my dad’s death certificate shows heart failure despite that nosocomial MRSA precipitated his demise). In trying to integrate medical error into the cause of death chart I’m combining fatal medical error incident reporting to Medicare with the Centers for Disease Control cause of death data.
What would it take to account for medical error deaths while accurately reducing the number of deaths reported due to other causes? Casting about a bit more granularly, although it’s unclear what NEJM’s interactive chart’s Accidents category includes, I suspect that medical error is not rolled in; the chart breaks accidents into motor vehicle and non-motor vehicle.
I think a lot about where the tipping points lay that start families on the slippery slope ending up in non-peaceful demises. On the other hand, it’s hard to fathom, in light of growing national end-of-life reporting, the nascent end-of-life conversation, and just how many troubling deaths occur (it seems that everybody has a story), that people don’t realize that dying peacefully in a medically managed milieu is filled with practical impediments even if a family is advance planned.
It is good to see deeper thought being brought to this subject by someone with a passion for it. This article pretty well summed up for me what we as patients need to know and equally what physicians, in particular, as well as nurses need to know and begin to deal with.
Elizabeth, I wish I would have known and had the presence of mind to do what you did regarding Dad’s recorded cause of death.
I have an article in press in the Journal of Patient Safety showing that preventable adverse events, aka medical errors, are associated with the deaths each year of about 440,000 Americans that have been hospitalized. In any case, medical errors are the third leading cause of death, but most are undisclosed. After publishing this article I read a piece by Beth Howard in AARP that cited the Centers for Disease control as a source for fatal medical error statistics she used in her article. During routine surgery in 2009, a very distracted pre-op anesthesiologist induced my intraoperative respiratory arrest.
Five of the top 16 lobby groups, one-third, are in the health industry, including the top two: drugs and insurance.
As a practicing primary care clinician, I would like to add a comment about a facet of this I see as rarely mentioned: the need for individuals WITHIN the system to recognize that every system is perfectly designed to give the results it gives (Bataldan) and that we are obligated to speak up about all the glitches we see and insist that they be evaluated and addressed as systemic problems rather than individual failures. We should be using our institutions’ error and incident reporting tools to report every late lab test, every lost message, every incorrect entry on a medication list, every communication failure, every scheduling error, every lab or x-ray report that makes it hard to find or understand the results, every aspect of our systems that inhibits or distracts from care.


Unless and until all clinicians own this part of the problem and speak up, the culture will continue to accept error as part of the cost of doing business.
Participatory Medicine is a model of cooperative health care that seeks to achieve active involvement by patients, professionals, caregivers, and others across the continuum of care on all issues related to an individual's health. In a recent report by the Institute of Medicine (IOM) the number of deaths attributable to medication errors range as high as 98,000 annually with approximately 1.5 million being injured.
With such staggering numbers can we afford to have our medical professional continue to make such grave and irresponsible errors that is costing us the lives of our loved ones? Medication errors occur anywhere within the drug prescribing system; from the distribution to administration of the drug, mistakes are made from the physician writing the prescription to the pharmacist dispensing it, to the medical personnel administering the medication. As a result of all these errors, The Medication Errors Reporting Program (MERP) was put into effect to assist with analyzing the causes of these medication errors while at the same time to offer possible solutions and recommendations to prevent further errors from occurring. Medication Errors needs to be documented and recounted to ascertain that the same missteps do not keep happening.
Problems with the equipment supplying the medication, such as the intravenous pump, insulin pens etc.
With so many modern technologies available at our finger tips today, yet medication mistakes continues to be on the rise, whether it is attributable to human error or not, we all must do our part to assist in preventing any further casualties from occurring from these medical mishaps.
Being Prepared a€“ this entails making a list of all prescription and non-prescription drugs, all supplements inclusive of vitamins, herbs and other mineral that you and the family take. Have your medication reviewed regularly a€“ If possible, once a year, have your medication list reviewed by your primary care physician, this ensures there are no dangerous combination, incorrect dosages or medication inappropriate to your age and medical circumstance. Utilize your pharmacist a€“ Today, most pharmacies offer free consultation on your medication management. Be proactive, prior to any type of hospital surgery- Prior to any type of surgery, consult your doctor as to which medication you may need to stop taking, if any, further after the procedure, dona€™t forget to ask them to explain any additional medication you are being administered and what effects, if any, they may have on you.
No health care professional including pharmacists wish to make any errors that will result in a patient injury. Both patients and regulatory agencies have taken the necessary steps to seek redress for harm caused by these medication mistakes. At theA Law Office of Igor Tarasov Esq.A we understand the complexities in filing a claim for medication errors.
At theA Law Office of Igor Tarasov Esq.A we help you to understand your judicial rights and the statute of limitations on your particular time-sensitive case. We explore all options available to assist you in recouping monetary damages for medical bills, all loss of wages, rehabilitation cost and home care cost. Schedule a free case evaluation today with an experienced New York Personal Injury Attorney at theA Law Office of Igor Tarasov Esq.A at 800. As part of our commitment to our clients, we always try to respond as quickly and carefully as possible to your legal needs.
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The 1953 operation was intended to treat HM’s epilepsy, but it had the side effect of leaving him unable to form new memories. A defining feature of IGE is that the seizures do not start from any particular place in the brain.
Wasn’t intra-cranial electrophysiology used at the time to narrow down the epileptogenic focus? His blog offers a look at the latest developments in neuroscience, psychiatry and psychology through a critical lens.
Drugs may have similar names and the order or prescription may be written wrong, written illegibly, or incorrectly transcribed.
The most common error is improper dosing of a medication, and in 1998, the FDA found that dosing errors caused 41% of fatalities resulting from medication errors. Every patient who receives a prescription for a medication is potentially at harm, despite the many benefits of effective medication management. If your doctor has wrongly prescribed a medication or if you were a hospital patient who received the wrong dose or wrong medication with serious consequences, you should consult a Chicago malpractice attorney at Passen Law Group for a review of your records.
There have been a number of lawsuits in the news as a result of alleged medical negligence in prescribing. Some doctors refer to these patients as “frequent fliers.” At one time, emergency departments would keep a card file with these patients, but that practice has been outlawed. Many overdoses occur in people who are treated by their doctors with a combination of narcotics and sedatives. In the past, knowing the risks of addiction and overdose, pharmaceutical representatives continued to encourage physicians to over-prescribe. An Alabama widower won $500,000 in a lawsuit after his wife died of an overdose from narcotics and sedative-hypnotic drugs. These physicians should be especially careful by screening their patients for drug abuse or addiction, and they should sign a pain contract, which allows them to terminate care if patients obtain narcotics from another physician. Sometimes these errors are not only due to lack of qualified staff but to failure to train and supervise employees. The 2006 study described harmful medication errors as 1.5 million incidences ranging from the prescription to administration. Additionally, interactions are not checked when new medications are prescribed and this can even be fatal in some instances, particularly with cardiac medications. Medications errors may be due to negligence and it is important to call attention to these systemic problems. Also tell about any problems your medicines have caused —such as a rash or stomach ache. Talk with your doctor and health care team about your options (choices) if you need hospital care.
The Institute of Medicine’s (IOM) landmark report, To Err is Human: Building a Safer Health Care System, concluded in 1999 that 44,000 to 98,000 annual deaths resulted from medical error.
As I learned more about medical error reporting, I came to realize that despite having been repeatedly identified as among the leading causes of death in America, the presence of fatal medical error wasn’t accounted for where it matters most: where and when medicine and people come together to explore end of life issues. I think that understanding the risk of fatal medical error is more likely when it’s presented in relationship to other major causes of death rather than solely as a gigantic number as in the landmark reports.
However, his death wasn’t ensured by acquiring MRSA; that required a range of communication failures around a scheduled surgery to drain the wrist infection where the MRSA lodged, which required general anesthesia due to his previously weakened heart.
Had we encountered the release form we would have asked questions and learned about typical hospital procedures suspending DNRs during surgery and for anywhere from two to forty-eight hours post-op (depending upon the facility’s rules). This communication failure, another type of error, led directly to Dad’s death because a failure to disclose meant that options were needlessly foreclosed. I wrote a book (Notes from the Waiting Room: Managing a Loved One’s (End of Life) Hospitalization) which has helped hundreds of people gain insight into advocating medically and re-visioning end of life in order to actualize our universal, yet vaguely-stated desires to die in peace. I added a fourth trajectory to Joanne Lynn’s three well-known charts tracing the slope of deaths due to cancer, organ failure, and cognitive decline. You’re probably familiar with the “X number of crashed jumbo jets daily” metaphor used to dramatically convey the number of annual fatal medical errors. I’ve made some strides around end-of-life matters as a lay person, but I’m at the limit of my abilities (and frustration) when it comes to solving how to integrate and correlate these two agencies’ data sets so that anyone citing the data is forced to use the combined, correlated whole. Since fatal medical error counts are widely disseminated and believed, why doesn’t this data appear in CDC data used to compile top causes of death charts, automatically causing a medical error category to appear in them? Participation that supports and leads to peaceful dying is a two-way street, requiring both more and less of providers, and a whole lot from the citizenry (a term I use because I have concluded that dying in peace is so huge a challenge in our complex milieu as to be an act of citizenship). Peaceful dying requires more honest answers in public forums where attendees voluntarily come. In this regard, participatory medicine would foment public participation by advising, even admonishing, the public to study up about end of life issues.
The easy ones are within medicine’s grasp because they’re factual and the data is readily available: account to the dying public for medical error’s role. Now that you’ve read this article go immediately to his on re-labeling medical error. I only wish only we had professionals sharing these stories inside these journals and all professional journals maybe progress would be made.


It would have been a small defiant act of some satisfaction (that we fired two nurses during his demise was not satisfying…).
My estimate includes errors of comission, omission, diagnosis, context, and communication as well as hospital acquired infections.
For example, the third man to walk on the moon, Pete Conrad, was injured in a motor cycle accident in 1999. My own research seems to indicate that CDC supplies disease cause of death data whereas Medicare supplies medical error incident reporting which IOM and OIG reports have extrapolated for their landmark reports on fatal medical error.
We’re going to be updating these numbers this year, but for now, that is the most current estimate we have for deaths. This implies that if medical errors were completely and accurately reported, we would have an annual iatrogenic death toll much higher than 783,936. Participatory medicine is an ethical approach to care that also holds promise to improve outcomes, reduce medical errors, increase patient satisfaction and improve the cost of care. The program invites consumers to confidentially report any errors by completing a report supported by relevant evidence. Whether it was a a€?near missa€™ incident or a hazardous situation or even a bad reaction, as a consumer, we need to be aware of the dangers associated with medication errors and the ensuing problems. Keep in mind that as time passes, the body changes, the medication that was acceptable for you 5 years ago may not have the same effect on you today, worse it may not even be necessary for you to continue taking.
Make use of this, it may be easier to speak with your pharmacist than your doctor, additionally, the pharmacist will detail whether your medicine must be taken alone or with a meal, what the possible side effects are as they are highly knowledgeable on the medication interactions, so consult your pharmacist to review that list. If you are unable to complete this task yourself, get a friend or family member to follow up and get all the pertinent details. They are aware that with any missteps, they are at risk for legal action for their errors; and lawsuits have proliferated along with these errors. Any medical professional, including pharmacist can and will be held legally liable for their errors. We understand that this type of negligence must be investigated and those responsible should be made to pay monetary damages and or have their practitionera€™s license revoked. Everyone who signs up gets full access to our entire library, including our curated collections. Our Standard license allows you to use images for anything, except large print runs over 500,000+ or for merchandising. Once you have downloaded your image, you have life-long rights to use it under the terms of the license purchased. This study, published by the Institute of Medicine, titled To Err Is Human: Building a Safer Health System, found that medication errors accounted for more than 7,000 annual deaths at that time.
In nearly half the cases in one study, patients taking a medication with a black box warning were not monitored appropriately. A list of drugs with a black box warning or post-market safety concerns can be found on the FDA Drug Safety website. Another family member was given the incorrect instructions for Coumadin, or warfarin, and ended up taking 10x the dose, putting him at high risk for an intracranial hemorrhage. Today, most states keep detailed prescribing records of scheduled drugs, and in some states, before writing a narcotic, a physician is obligated to check the state database to determine if the patient has been “doctor-shopping,” or visiting a number of physicians to acquire a steady supply of narcotic drugs.
In its place, however, there is a computerized registry that can be easily accessed by physicians to determine with some likelihood if a patient is abusing his or her prescriptions. Many heroin addicts, who are by and large a young population, get their start with prescription drug experimentation, often stealing drugs from their parents or grandparents. A nurse in Mississippi died of an overdose in the hospital when her doctor prescribed one opiate when she was already under the influence of another powerful opiate. However, after signing such a contract, they should also check the state registry to be certain the patient is compliant.
There should be protocols and guidelines for facilities in which these drugs are utilized, and failure to follow created protocols is malpractice. Doctors may right the wrong medication, or may fail to look up interaction with other drugs. This will help your doctor make sure that your new medicine does not cause problems with ones you already take.
Death cause data and medical error incident reporting data seem to exist separately in public records.
Starting in 2003, HealthGrades’ Patient Safety in American Hospitals showed that about 195,000 annual deaths result from medical error. Medical error has never been mentioned in any provider- or university-sponsored public end of life panel discussion I’ve witnessed, and it never appears in those “top ten causes of death” charts that pop up periodically such as the one published in the New England Journal of Medicine’s 200th anniversary issue (June 2012).
We would have learned that post-op intubation is rarely required, and I would have advised Dad to go for the surgery. Why, then, would an academic professional journal in a 2012 anniversary issue fail to include medical error fatalities when replicating a top ten causes chart using more recent data? Copyright for this article is retained by the author, with first publication rights granted to the Journal of Participatory Medicine.
The best we can do at the moment is to find a blog site member forum such as the SOCIETY FOR PARTICIPATORY MEDICINE. A doctor in the ER where he was taken failed to realize that he was bleeding from internal injuries, and he died. In 1994, Leape said his figure of 180,000 medical mistakes resulting in death annually was equivalent to three jumbo-jet crashes every two days. We dona€™t want just to take care of your legal needs quickly, we want to take care of them correctly.
If at any time you're unsatisfied with your experience with us, you can cancel your subscription. An adverse drug reaction is any response to a drug that occurs at a dose normally used for therapy that results in a noxious effect that is not the result of medication error.
This happens more frequently than the general public might imagine, and, because physicians are vested with the power to prescribe powerful drugs, they have the responsibility to prescribe cautiously and responsibly. Many older people in the country complain of chronic pain disorders, and, rather than prescribing physical therapy, non-narcotic analgesics, or topical treatments, doctors today tend to write prescriptions for narcotics. Since doctors are dependent upon these surveys for employment, they are frequently afraid to deny narcotics to patients who may be drug abusers or addicts. Accounting for medical error as among the leading causes of death would require these data sets be integrated in a way that would force error to appear in causal compilations. Although these were not fatal errors they certainly didn’t help a patient described to me as the most critically ill in the facility. If post-op intubation were in his case, I would have had it stopped after whatever fixed timeframe Dad and the docs might have negotiated (a “time-based trial”).
My two consolations are that he, lucidly, made the decision himself; and that this snafu stimulated me to learn an enormous amount about resuscitation matters which has greatly informed my ability to act as a medical advocate or proxy when the need next arises. In 2012 I introduced two new works: Windrum’s Never Say Die Rap™, an absurd musical statement of our quandary, and Windrum’s Matrix of Dying Terms™, a linguistic thanatological work introducing new terms that identify and name all sixteen fundamental dying situations, this to replace the sole word “dying” which fails to forecast or describe dying realities in our complex age. Even as medicine persists in error-prone ways, it also valiantly acts to try to fill that citizen void by trying to solve problems for the citizenry that we ought to be solving for ourselves.
If medicine owns its numbers and acts on them, who knows what we citizens may do for ourselves?
All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. As soon as I get reprints, I’ll send anyone a free copy if I have their home address.
Jessie was a founding editor of JoPM and continues to have a positive impact on the field of participatory medicine and the cause of patient empowerment. Doctors and hospital pharmacists may fail to check drug interactions, resulting in serious side effects or even death. This trend is a real change, as narcotics were primarily limited in the past to patients suffering from cancer pain. At the same time, doctors don’t want to deny pain medications to patients who may legitimately be suffering. Let us know the nature of the problem, the Web address of what you want, and your contact information. Department of Health and Human Services Office of Inspector General report, Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries, found up to 180,000 deaths annually attributable to medical error. The anesthesiologists refused it but failed to inquire what lay behind the stipulation (Dad’s experience of Mom’s terminal hospitalization) or to offer us any options whatsoever. Yet even this is undermined by a medical system that, to its credit, advises us to arrive with an advocate in tow, but doesn’t really say why (too scary) or how (too complicated). By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings. Doctors may ignore or overlook compromised kidney or liver function, failing to reduce doses or discontinue harmful drugs.
When a dose is calculated by a doctor or nurse to be given IV, the drug dose may be off by a factor of ten or more, simply by misplacing a decimal point.



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