Dangerous Road Ahead

More than 1 in 10 patients are harmed in the course of their medical care…………..and half of those injuries are preventable. 

And there she was, by the time she reached the inpatient geriatric psychiatry inpatient ward in serotonin syndrome delirium, Ms. X was on Lexapro, Prozac, Effexor, Risperidone, Ingrezza, Austedo and Trazodone according to medication reconciliation. Records from the two recent hospitalizations in the last 3 days indicates each time the medication reconciliation was completed, old and other medications were added, ordered, and administered. Case in point the article (1) where it reports on a study (2) that reports:

“We need strategies in place to detect and correct the key causes of patient harm in health care.” “Our study finds that most harm relates to medication, and this is one core area that preventative strategies could focus on.”

            Researchers sought to determine the prevalence of preventable patient harm in hospitals, primary care, and various specialties. They used a systemic review and meta-analysis to estimate the prevalence of harm from five electronic databases and a pooled sample of 337,025 patients (3). Like the case highlighted above, incidents relating to drugs and other therapies accounted for 49 percent of the harms, and injuries related to surgical procedures accounted for 23 percent. The above case is highlights the preventable nature of such errors. Had attention to detail been paid, Ms. X would not have been subjected to the poly-pharmacy that caused the delirium. There is evidence that up to 30% of the cases of delirium in elderly hospitalized patients is caused by medication toxicity to include psychotropic medications (4). The current case highlights a learning point described by Kosari SA (2014)(5):

“Delirium is a multifactorial disorder that can be precipitated by any medical condition in a susceptible person, therefore a comprehensive history and physical (H&P) examination is imperative to guide diagnostic investigations.”


  1. https://www.nbcnews.com/health/health-news/medical-mistakes-harm-more-1-10-patients-many-are-preventable-n1030996
  2. Panagioti Maria, Khan Kanza, Keers Richard, Abuzour Aseel, Phipps Denham, Kontopantelis, Evangelos et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis BMJ 2019; 366 :l4185, https://www.bmj.com/content/366/bmj.l4185
  3. https://www.healthexec.com/topics/quality/medical-mistakes-harm-1-20
  4. Moore, A.R. & O’Keeffe, S.T. Drugs & Aging (1999) 15: 15. https://doi.org/10.2165/00002512-199915010-00002
  5. Kosari SA, Amiruddin A, Shorakae S, Kane R. A rare cause of hypoactive delirium. BMJ Case Rep. 2014;2014:bcr2014205382. Published 2014 Oct 19. doi:10.1136/bcr-2014-205382

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Robert Duprey MD

Robert is a 2nd career physician (MD); a combat Veteran with the US Army; a former psychiatric nurse practitioner; an independent researcher; a medical writer; and now having passed USMLE Steps 1, 2CK, 2CS, and 3, is a residency applicant.

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6 Responses

  1. Bridget Reidy says:

    People who do a lot of geriatrics know that there’s even more of these medications errors than what the EHR can find, because the hospital EHR and hospital providers don’t care to receive any info from the outpatient world, even when we beg them by pushing it in.

  2. Steve O' says:

    If people really care about medical error, misdiagnosis and maltreatment, they would realize that in the vast majority of cases, such problems only require a flash of intellect by the trained mind. In this case, a decent analysis doesn’t require a psychiatrist. In fact, it requires only recourse to a list of medications, and if they’re printed on paper rather than run through a Pharmacy App, it’s the same process. Neither the Pharmacy App nor the individuals on the Caregiving Club picked up on this mess.
    This patient’s care never received the flash of intellect needed to ponder in one sweep escitalopram, fluoxetine, venlafaxine, risperidone, valbenazine, deutetrabenazine, and trazodone. It only needs the lightest fund of knowledge to realize that this is a list of five psychiatric medicines, four targeting depression and one thought disorders; and two similar medicines that affect tardive dyskinesia and dopamine-mediated movement disorders.
    That’s a boatload of shrink candy.
    Also, the differential diagnosis of delirium expands with age.
    But clearly, no single mind had the opportunity to place these medicines together for one sweep of the eye. It’s probably because those with the capacity to discover and treat iatrogenic delirium were busy filling out checklists on “grandmother’s shoe size,” “grandfather’s birth weight,” and “number of gender-fluid descendants,” new-onset hirsutism or examining for clitoral enlargement, earwax and tongue fasciculations.
    Mistakes are happening more and faster, because the patient is swept out from under the scrutiny of a single individual with an open mind and lacking some agenda, and the care is instead diced up into microslices scattered throughout the increasingly illegible “Medical Record.”
    One of my pet peeves as an outpatient physician is the patient who comes in, says he went to ER du Jour for chest pain, “they ran all the tests and it was nothing.” People think these little slices of care add up to a medical record. They don’t. Ask our poor patient.
    Americans are dying from their own myths about healthcare, and the myth that fragmentation of care doesn’t matter is one of the worst. To err is human; but to remedy is human, to heal is human, too. Your rad doc app only makes things worse.

    • Pat says:

      That made me laugh.

      Considering all the contrived bullshit everyone has to DOCUMENT !!!, it’s a wonder we keep as many patients alive as we do.

      But does grandma, or her family, or her handlers ever question that it is they – through their politicians and lawyers – who require these obfuscations to true care?

  3. Thomas David Guastavino says:

    Always bear in mind that those that claim patient harm still have not properly made the distinction between a complication and a true medical error.

    • Steve O' says:

      Neil deGrasse Tyson announced, after the shootings in El Paso and Ohio, that while these events occurred, some 500 Americans died of medical error.
      In the discussion of climate change and such, the scientists talk about “forcings,” which mean systems that are predisposed towards positive feedback. That means, the more they change, the more impetus they are given to change further. In layman’s terms, positive feedback means “KABOOM!” You can’t build a bomb without positive feedback. And everything that has net positive feedback is a type of bomb, in a sense.
      It seems that EVERY SINGLE THING that the American Medical Machine changes, the more widely, intensely and pervasively horrible disasters occur. Our leaderships’ high-handed pressure to change more, faster, NOW – means the greaterthe positive feedback is forced, and the more extreme the KABOOM will be.
      If you’re in a hole, stop digging.
      Tyson went on to mention the usual litany of “ordinary deaths” in America over the weekend. He would like numeracy to numb out the shooting issue’s severity – but when it comes to MEDICAL ERROR, of course, something could be done. Thanks, Neil.

    • Pat says:

      Excellent point.

      And I’m still looking forward to the system that will accurately catalogue ACTUAL meds taken after combining not only iatrogenic polypharmacy, but patient recollections, variable ingestion schedules, and advice from relatives. Good freakin’ luck.

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