Intended for healthcare professionals

Fillers A medical mishap

What came first and what seems worse

BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7329.102 (Published 12 January 2002) Cite this as: BMJ 2002;324:102
  1. Hugh Tunstall-Pedoe, professor of cardiovascular epidemiology
  1. University of Dundee

    Clinical mishaps are likely to be overlooked and buried—or concealed by sympathetic patients, relatives, or colleagues. Mine was very public, the talk of the hospital. Doctors came from far and wide to admire it, and if it wasn't photographed for a textbook it should have been. As an exchange student in the United States, I was asked to do a tuberculin test on a patient with mysterious shadows in her lungs. Tuberculin came in twin packs labelled “first strength” and “second strength.” I misunderstood the instructions and used the wrong one. The patient had an extreme response—a black carbuncle on her arm the size of a plum. Everyone was kind about it, particularly the victim. In those days patients entering teaching hospitals cost-free did not expect them to be risk-free. But they did expect their experience to be exotic. This certainly …

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