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PART I Medical Harm Ihor B. Gussak William J. Kostis . . . ​ ωϕελεειν η μη βλαπτειν . . . ​ ( . . . ​ to help, or at least to do no harm . . . ​ ) Hippocrates, Epidemics, Bk. I, Sect. XI, c. 400 b.c. INTRODUCTION This book requires a caveat, one that all of its authors kept in mind while writing: the discussion of iatrogenicity is not motivated by emotional appeals, although we recognize with deep sadness that countless patients, ­ family, friends, and medical personnel have been touched by iatrogenic complications or medical harm. This book is intended to lay a foundation for establishing iatrogenicity as a new clinical discipline . It is meant to serve as a reference for caregivers in better understanding the preventable nature of iatrogenic harm and learning from their own and ­ others’ ­ mistakes and misconceptions without accusing or blaming anyone. Rather, maintaining a scientific approach to and perspective on medical harm, ­ whether intended or unintended, is crucial to furthering medicine. Moreover, we are cautious about calling iatrogenicity a “prob­ lem.” The impor­ tant message is that facts and statistics ­ matter; this book was not written to point fin­ gers or expose ill practices. We aim to prove that iatrogenicity has always been a part of medicine since its beginning and ­ will continue to be for as long as medicine exists as an art and a science. We hope that this chapter finds you well, ­ causes you to raise questions, and increases your awareness for ­ doing what is right not only for your patient but also for yourself, the clinician, student, nurse, or caregiver for whom we wrote this book. Defining Iatrogenicity It is impor­ tant to review the definitions of health, medicine, medical harm, and adverse event. The word health comes from the word for ­whole. To heal means to restore to a state of ­ wholeness, soundness, or integrity. “. . . Health is completeness and perfection of organ­ ization, fitness of life, freedom of action, harmony of functions, vigor and freedom from all pain and corruption —in a phrase, it is ‘a sound mind in a sound body’” (1). CHAPTER 1 Iatrogenicity Definition, History, and Modern Context Maria L. Gussak, Ihor B. Gussak, and John B. Kostis 6 / Iatrogenicity postponed, yet preventable or avoidable harm to the ­ human body or mind by ­ either action or inaction (failure to prevent) of the medical caregiver (e.g., nurse, physician) resulting in discomfort, injury, disability, or death. Just as white light has seven component colors when passed through a prism, the concept of iatrogenicity has seven inherent components. 1. Any intentional or unintentional . . . ​ Determining intentionality is not a requirement in deciding ­ whether harm is of iatrogenic origin­ because ­ whether it was intended does not ­ matter. It is impor­ tant not to get lost in subjective conclusions or motives about ­ whether a physician had malice in choosing and executing a treatment. Thus, accidents are included just as errors, misjudgments, side effects, and unexpected adverse events are. 2. . . . ​ immediate or postponed . . . ​ Timing can be subjective and open to interpretation . For one person, medical harm might be clearly attributable to delay of care, while another might deem it prudent to wait and try other ave­ nues of treatment. Fortunately, physicians are trained to justify their decision-­ making pro­ cess, and it is understood that not all may agree. The point is to acknowledge that timing itself can be a source of iatrogenicity. This includes delay of care, delay of diagnosis, postponed decision making or appointments, or even treatment and diagnosis rendered too quickly. 3. . . . ​ yet preventable or avoidable . . . ​ Preventability or avoidance is key to iatrogenicity . Can side effects or adverse events be prevented or avoided? Preventability is a challenging notion ­ because physicians treat according to the practiced standards of care—­ standards that often have difficulty keeping up with the latest evidence-­ based practices, and can sometimes become outdated or even dismissed as poor practice . Current practices may be considered barbaric in the ­ future, just as past practices that ­ were used inappropriately (such as bloodletting) are rejected ­today. “Not only is health a normal condition, but it is a duty not only to attain it but to maintain it” (2). Taber’s Cyclopedic Medical Dictionary defines medicine as (a) a drug or remedy and (b) the act of maintenance of health, and prevention and treatment of disease and illness. Note the emphasis on a health-­and prevention-­ based system. Medical harm is defined as an outcome that negatively affects a patient’s health and/or quality of life, whereas adverse event is an event that results in unintended harm to...


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