I was looking for something else in a database of cases handled by the N. C. Office of the Chief Medical Examiner when I stumbled across a surprising word, in all caps, “MISADVENTURE.”
I was an investigative reporter at The News & Observer in Raleigh and I was intrigued. Was this what I suspected? Were these people who had been accidentally killed while undergoing medical treatment?
Well, yes, that’s pretty much it.
A medical misadventure is an unlucky event, for everyone involved, an event in which a patient is injured or killed. All the patients named in that database, of course, were dead.
Some misadventures are due to negligence, some are due to accidents, pure and simple — a doctor punctured something he shouldn’t have punctured and the patient bleeds out on the table or a nurse administers the wrong medicine with fatal results. Every medical misadventure should be carefully investigated by licensing officials, but that wasn’t happening.
The International Statistical Classification of Diseases and Related Health Problems [ICD] devotes page after page to all the things that can go wrong, to “misadventures,” a word I had never heard used in that context. No surprise there — there’s a warehouse full of things I’ve never heard of.
But this will surprise you:
Members of the N.C. Medical Board, good doctors who were responsible for weeding out bad doctors, said they didn’t know know about misadventures either. The chairman of the medical board’s investigative committee told me that as “incredible” as it might sound, members of his committee had never heard the term “misadventure.”
I didn’t think think is was “incredible” that none of them had heard about medical misadventures, I thought it was unbelievable.
Postscript: A few days later the N.C. Medical Board voted to gather information about “misadventures” from the Chief Medical Examiner office.
“Investigative analysis of these cases will be promptly carried out, and appropriate action or actions will be taken by the N.C. Medical Board,” the board’s statement said.
Coming Monday: He Remembered Hundreds; I Forgot One