A short history of medical human error

In his rather disturbingly-titled book Bad Medicine: Doctors Doing Harm Since Hippocrates, the historian David Wootton dug into Medicine’s murky past to unearth abundant artefacts of its damaging theories and practices that put the profession to shame. Wootton passed a sweeping condemnation of Galenic and Hippocratic Medicine which advocated such principle as the four humours, and such harmful practices as blood letting. He was particularly disapproving of what he said were the ‘limits of imagination’ and the ‘conservatism of institutions’ which enabled the medical fraternity to hold out against such truisms as germ theory, with the resultant slow progress in the prevention of infections.

https://wellcomeimages.org/indexplus/image/L0041074.html, CC BY 4.0, Link

It is however discouraging that the types of disasters highlighted by Wootton were not confined to Medicine’s distant past. In his seminal book, Modern Medical Mistakes: Major Errors of Treatment in the Twentieth Century, the paediatric cardiologist Edward Lambert demonstrated that Medicine’s recent history is littered with large-scale tragedies. He reviewed a sad litany of adversities unleashed by the medical establishment on swathes of the population. Unlike the isolated mishaps that result from the mistakes of individual doctors or health institutions, these were catastrophes let loose on a sizeable number of the unsuspecting public. Lambert showed that ‘in previous centuries, on the whole, more patients were harmed then were cured by the remedies used by doctors’. Among the multitude of prominent misguided interventions he listed were the treatment of threatened abortion with synthetic progestins which resulted in masculinization of female fetuses, and the treatment of premature infants with oxygen resulting in retrolental fibroplasia. Other less dramatic but equally devastating adverse effects of drugs included chronic mercury poisoning from laxatives and teething powders; silver toxicity from antiseptic preparations; thallium poisoning from depilatory preparations, and agranulocytosis from amidopyrine.

Mercury1. Mrs Pugliano on Flickr. https://www.flickr.com/photos/mrspugliano/5351056746

Most concerning for Dr. Lambert was the pattern he observed of medical regulatory agencies ignoring concerns about the toxicity of drugs, and this is perhaps best reflected in the thalidomide crisis. Used in the treatment of morning sickness, the drug resulted in catastrophic limb defects called phocomelia. Despite the early warnings that thalidomide was unsafe, it was prescribed to countless pregnant women across the world – except in the Untied States where it was not approved by the Foods and Drug Administration because of the vigilance of Frances Kelsey who was concerned about the drug’s clinical trial data.

Thalidomide and the Infinite Sadness. Kent Yoshimura on Flickr. https://www.flickr.com/photos/kent_yoshimura/6224263039

Dr Lambert was also concerned about how long it takes for the medical profession to take action after a clear link has been established between a drug and its serious adverse effect. Equally concerning for him was the way the risks of drugs were assessed in substandard clinical trials, and the way large pharmacological companies withheld or falsified clinical trial results, as happened with triparanol, a synthetic anti-cholesterol drug which was eventually withdrawn on account of a variety of side effects, from alopecia to visual loss.

Medication. Gatis Gribusts on Flickr. https://www.flickr.com/photos/gatiuss/5223834995

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With that quick run through of the history of medical error, we have concluded our introductory blog posts to the subject of human error and patient safety. In the next blog post, we will look at the four foundations of human error which will form the backbones of this blog.

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