Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-848d4c4894-x24gv Total loading time: 0 Render date: 2024-04-30T12:08:53.130Z Has data issue: false hasContentIssue false

Chapter 31 - Iatrogenic Deaths in Elders

Published online by Cambridge University Press:  11 July 2020

By
Joseph A. Prahlow
Edited by
Kim A. Collins  and
Roger W. Byard
Kim A. Collins
Affiliation:
LifePoint Inc, South Carolina
Roger W. Byard
Affiliation:
University of Adelaide
Get access

Summary

“Iatrogenic deaths” represent an important topic within any discussion regarding public health and well-being, with potential implications for global, national, and local healthcare systems, care providers, and patients. A 1999 report of the United States (US)

Type
Chapter
Information
Geriatric Forensic Medicine and Pathology , pp. 554 - 578
Publisher: Cambridge University Press
Print publication year: 2020

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Kohn, L.T., Corrigan, J.M., and Donaldson, M.S., eds., To Err Is Human: Building a Safer Health System (Washington DC: National Academy Press, 2000).Google Scholar
Dictionary.com [Internet] Definition of “iatrogenic;” updated 2017. www.dictionary.com/browse/iatrogenic?s=t (accessed July 6, 2017).Google Scholar
Schmidt, J.E., Reversicon – A Medical Word Finder (Springfield, IL: Charles C. Thomas, 1958), p. 290.Google Scholar
Webster’s 1913 Dictionary [Internet]. Definition of “medication;” updated 2017. www.webster-dictionary.org/definition/Medication (accessed July 6, 2017).Google Scholar
US Food and Drug Administration [Internet]. Washington, DC: Food and Drug Administration; 2017. Definition of a Drug. Updated April 2017; www.fda.gov/drugs/resourcesforyou/healthprofessionals/ucm553116.htm (accessed July 6, 2017).Google Scholar
Dictionary.com [Internet]. Definition of “therapy;” updated 2017. www.dictionary.com/browse/therapy?s=t (accessed July 6, 2017).Google Scholar
Webster’s 1913 Dictionary [Internet]. Definition of “medical procedure;” updated 2017. www.webster-dictionary.org/definition/Medical%20procedure (accessed July 6, 2017).Google Scholar
Webster’s 1913 Dictionary [Internet]. Definition of “medical;” updated 2017. www.webster-dictionary.org/definition/medical (accessed July 6, 2017).Google Scholar
Webster’s 1913 Dictionary [Internet]. Definition of “procedure;” updated 2017. www.webster-dictionary.org/definition/procedure (accessed July 6, 2017).Google Scholar
US Food and Drug Administration [Internet]. Washington, DC: Food and Drug Administration; 2017. Definition of “medical device;” updated April 2017. www.fda.gov/medicaldevices/deviceregulationandguidance/overview/classifyyourdevice/ucm051512.htm (accessed July 6, 2017).Google Scholar
Prahlow, J.A., Medical devices. In Collins, K.A., ed., Autopsy – Performance & Reporting, 3rd edn (Northfield, IL: College of American Pathologists, 2017), pp. 275–288.Google Scholar
US Food and Drug Administration [Internet]. Washington, DC: Food and Drug Administration; Classification panels of medical devices; updated April 2017. www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/Overview/ClassifyYourDevice/ucm051530.htm (accessed July 6, 2017).Google Scholar
US Food and Drug Administration [Internet]. Washington, DC: Food and Drug Administration. FDA class I-III; updated April 2017. Available from: www.fda.gov/medicaldevices/deviceregulationandguidance/overview/generalandspecialcontrols/default.htm (accessed July 6, 2017).Google Scholar
Perper, J.A., Kuller, L.H. and Shim, Y.K., Detection of fatal therapeutic misadventures by an urban medico-legal system. J Forensic Sci, 38 (1993), 327–338.Google Scholar
Krehbiel, K., Matshes, E.W., Pinckard, K.J. and Lathrop, S., Medical therapy-related deaths and the medical examiner. Acad Forensic Pathol, 5 (2015), 421–435.Google Scholar
Paula, P., Pottinger, I., Kordina, N., Schneider, B. and Risser, DU, Iatrogenic death: a review of cases from 1990–2000 investigated at the department of forensic medicine, Vienna.Wien Klin Wochenschr, 123 (2011), 526–530.CrossRefGoogle Scholar
Gill, J.R., Goldfeder, L.B. and Hirsch, C.S., Use of “therapeutic complication” as a manner of death. J Forensic Sci, 51 (2006), 1127–1133.Google Scholar
Wang, M. and Lau, G., When is a peri-procedural death iatrogenic in nature? Forensic Sci Med Pathol, 8 (2012), 23–33.Google Scholar
Knight, B., The role of the pathologist in the investigation of iatrogenic deaths. Malaysian J Pathol, 14 (1992), 7–11.Google Scholar
Lau, G., Peri-operative deaths in Singapore: a forensic perspective in a study of 132 cases. Ann Acad Med Singapore, 23 (1994), 351–357.Google Scholar
Bell, M.D. and Dolinak, D., Artifacts of resuscitation and complications of medical therapy. In Dolinak, D., Matshes, E. and Lew, E., eds., Forensic Pathology – Principles and Practice (Burlington, MA: Elsevier Academic Press, 2005), pp. 317–327.Google Scholar
McGuire, A.R., DeJoseph, M.E. and Gill, J.R., An approach to iatrogenic deaths. Forensic Sci Med Pathol, 12 (2016), 68–80.CrossRefGoogle ScholarPubMed
Adams, V.I., Flomenbaum, M.A. and Hirsch, C.S., Trauma and disease. In Spitz, W.U., ed., Spitz and Fisher’s Medicolegal Investigation of Death – Guidelines for the Application of Pathology to Crime Investigation, 4th edn (Springfield, IL: Charles C. Thomas, 2006), pp. 436–459.Google Scholar
DiMaio, V.J. and DiMaio, D., Topics in forensic pathology. In DiMaio, V.J. and DiMaio, D., Forensic Pathology, 2nd edn (Boca Raton, FL: CRC Press, 2001), pp. 465–488.Google Scholar
Prahlow, J.A., Miscellaneous topics. In Prahlow, J.A., Forensic Pathology for Police, Death Investigators, Attorneys, and Forensic Scientists (New York, NY: Springer/Humana Press, 2010), pp. 539–591.Google Scholar
DiMaio, V.J. and DiMaio, D., Nursing home deaths. In DiMaio, V.J. and DiMaio, D., Forensic Pathology, 2nd edn (Boca Raton, FL: CRC Press, 2001), pp. 489–498.Google Scholar
Saukko, P. and Knight, B., Deaths associated with surgical procedures. In Saukko, P. and Knight, B., Knight’s Forensic Pathology, 3rd edn (Boca Raton, FL: CRC Press, 2004), pp. 480–491.Google Scholar
Caplan, M.J., Medical examiner’s experience with the evaluation of deaths associated with complications of diagnostic and therapeutic procedures (therapeutic complications/periprocedural deaths) – revisited (abstract). American Academy of Forensic Sciences Annual Meeting Proceedings (Colorado Springs, CO: American Academy of Forensic Sciences, 1999), pp. 164–165.Google Scholar
Reay, D.T., Eisele, J.W., Ward, R., Horton, W. and Bonnell, H.J., A procedure for the investigation of anesthetic/surgical deaths. J Forensic Sci, 30 (1985), 822–827.Google Scholar
Prahlow, J.A., Therapy-related deaths. American Society for Clinical Pathology Check Sample, Forensic Pathology, FP 02–1 (2002), 1–18.Google Scholar
Prahlow, J.A. and McClain, J.L., Death due to medical therapy. In Froede, R.C., ed., Handbook of Forensic Pathology, 2nd edn (Northfield, IL: College of American Pathologists, 2003), pp. 381–392.Google Scholar
Tawadros, A.M. and Prahlow, J.A., Death related to nasal surgery – case report with review of therapy-related deaths. Am J Forensic Med Pathol, 29 (2008), 260–4.CrossRefGoogle ScholarPubMed
Barranco, R., Leoncini, A., Molinelli, A. and Ventura, F., A fatal case of iatrogenic aortic arch rupture occurred during a tracheostomy. Forensic Sci Int, 259 (2016), e5–e8.Google Scholar
Wang, M., Death due to extensive cervicomedullary infarction following iatrogenic vertebral artery occlusion. Forensic Sci Med Pathol, 8 (2012), 334–337.Google Scholar
Bell, M.D., Sudden death due to intravascular hemolysis after bladder irrigation with distilled water. J Forensic Sci, 37 (1992), 1401–1406.Google Scholar
Cohle, S.D. and Delavan, J.W., Coronary artery compression by Teflon pledget granuloma following aortic valve replacement. J Forensic Sci, 42 (1997), 945–946.Google Scholar
Durao, C., Barros, A., Guerreiro, R. and Pedrosa, F., “Death by a thread” – peritonitis due to visceral perforation by a guide wire, during proximal femur osteosynthesis with DHS: a fatal case and legal implications. Forensic Sci Int, 249 (2015), e12–e14.Google Scholar
Cina, S.J., Raso, D.S., Crymes, L.W., and Upshur, J.K., Fatal suture embolism to the left anterior descending coronary artery – a case report and review of the literature. Am J Forensic Med Pathol, 15 (1994), 142–145.Google Scholar
Turillazzi, E., Bello, S., Bonsignore, A., Neri, M., Riezzo, I. and Fineschi, V., Retrospective analysis of anaesthesia-related deaths during a 12-year period: looking at the data from a forensic point of view. Med Sci Law, 52 (2012), 112–115.CrossRefGoogle ScholarPubMed
Li, W., Zhang, L., Liang, Y., Tong, F. and Zhou, Y., Sudden death due to malignant hyperthermia with a mutation of RYR1: autopsy, morphology and genetic analysis. Forensic Sci Med Pathol, 13 (2017), 444–449.Google Scholar
Cao, X., Cui, Y., White, P.F., Tang, J. and Ma, H., Central anticholinergic syndrome vs. idiosyncratic reaction triggered by a small IV dose of atropine. Acta Anaesth Scandin, 60 (2016), 270–273.Google Scholar
Vervloet, D., Nizankowska, E., Arnaud, A., et al. Adverse reactions to suxamethonium and other muscle relaxants under general anesthesia. J Allergy Clin Immunol, 71 (1983), 552–559.Google Scholar
Cook, T.M. and MacDougall-Davis, S.R., Complications and failure of airway management. Brit J Anaesth, 109 Suppl 1 (2012), i68–i85.Google Scholar
Pazanin, L., Misak, V.B., Goreta, N., Marekovic, Z. and Petrovecki, V., Iatrogenic tracheal laceration causing asphyxia. J Forensic Sci, 53 (2008), 1185–1187.Google Scholar
Ray, D.C. and Drummond, G.B., Halothane hepatitis. Br J Anaesth, 67 (1991), 84–99.Google Scholar
Gelven, P.L., Cina, S.J., Lee, J.D. and Nichols, C.A., Massive hepatic necrosis and death following repeated isoflurane exposure. Am J Forensic Med Pathol, 17 (1996), 61–64.Google Scholar
Turner, G.B., O’Rourke, D., Scott, G.O. and Beringer, T.R.O., Fatal hepatotoxicity after re-exposure to isoflurane: a case report and review of the literature. Eur J Gastroenterol Hepatol, 12 (2000), 955–959.Google Scholar
Horlocker, T.T. and Wedel, D.J., Infectious complications of regional anesthesia. Best Pract Res Clin Anaesthesiol, 22 (2008), 451–475.CrossRefGoogle ScholarPubMed
Villaverde, R.V., Vanhaebost, J., Grabherr, S. and Palmiere, C., Pulmonary artery rupture during Swan-Ganz catheterisation: a case report. Legal Med, 16 (2014), 76–80.Google Scholar
de Roux, S.J. and Sgarlato, A., Upper and lower gastrointestinal endoscopy mortality: the medical examiner’s perspective. Forensic Sci Med Pathol, 8 (2012), 4–12.Google Scholar
Fuhs, A.K. and Prahlow, J.A., Death resulting from pneumocephalus complicating endoscopic food bolus retrieval in a patient with eosinophilic esophagitis. Acad Forensic Pathol, 6 (2016), 703–708.CrossRefGoogle Scholar
Hunsaker, D.M. and Hunsaker, J.C., Therapy-related café coronary deaths – two case reports of rare asphyxia deaths in patients under supervised care. Am J Forensic Med Pathol, 23 (2002), 149–154.Google Scholar
Craft, L. and Prahlow, J.A., From fecal impaction to colon perforation. Am J Nursing, 111 (2011), 2–7.Google Scholar
Tsokos, M. and Puschel, K., Iatrogenic Staphylococcus aureus septicaemia following intravenous and intramuscular injections: clinical course and pathomorphological findings. Int J Legal Med, 112 (1999), 303–308.Google Scholar
Roquero, L.P., Camelo-Piragua, S. and Schmidt, C., Cerebral air embolism – a clinical, radiologic and histopathologic correlation. Am J Forensic Med Pathol, 37 (2016), 241–244.Google Scholar
Verslegers, L., Schotsmans, K., Montagna, M., et al., Severe bilateral subdural hematomas as a complication of diagnostic lumbar puncture for possible Alzheimer’s disease. Clin Neurol Neurosurg, 152 (2017), 95–96.Google Scholar
Ventura, F., Fracasso, T., Leoncini, A., Gentile, R. and de Stefano, F., Death caused by toxic epidermal necrolysis (Lyell syndrome). J Forensic Sci, 55 (2010), 839–841.CrossRefGoogle ScholarPubMed
Poklis, A., Mackell, M.A. and Tucker, E.F., Tissue distribution of lidocaine after fatal accidental injection. J Forensic Sci, 29 (1984), 1229–1236.Google Scholar
Kumar, V., Abbas, A.K. and Aster, J.C., Diseases of the immune system. In Robbins and Cotran Pathologic Basis of Disease (Philadelphia, PA: Elsevier Saunders, 2015), pp. 185–264.Google Scholar
Collett, B.A. and Lantz, P.E., Fatal anaphylactoid reaction to intravenous radiocontrast material. American Society for Clinical Pathology Check Sample, Forensic Pathology, FP-204 (1995), 49–64.Google Scholar
Schwartz, L.B., Metcalfe, D.D., Miller, J.S., Earl, H. and Sullivan, T., Tryptase levels as an indicator of mast-cell activation in systemic anaphylaxis and mastocytosis. N Engl J Med, 316 (1987), 1622–1626.Google Scholar
Yunginger, J.W., Nelson, D.R., Squillace, D.L., et al., Laboratory investigation of deaths due to anaphylaxis. J Forensic Sci, 36 (1991), 857–865.CrossRefGoogle ScholarPubMed
Edston, E. and van Hage-Hamsten, M., B-Tryptase measurements post-mortem in anaphylactic deaths and in controls. Forensic Sci Int, 93 (1998), 135–142.Google Scholar
Randall, B., Butts, J. and Halsey, J.F., Elevated postmortem tryptase in the absence of anaphylaxis. J Forensic Sci, 40 (1995), 208–211.Google Scholar
Prahlow, J.A., Implanted medical devices encountered at autopsy, In K.A. Collins, ed., eMedicine from WebMD [Internet]. Updated August 4, 2016. emedicine.medscape.com/article/1681045-overview (accessed July 6, 2017).Google Scholar
Shields, L.B.E., Hunsaker, D.M. and Hunsaker, J.C., Iatrogenic catheter-related cardiac tamponade: a case report of fatal hydropericardium following subcutaneous implantation of a chemotherapeutic injection port. J Forensic Sci, 48 (2003), 414–418.Google Scholar
Prahlow, J.A., Guileyardo, J.M. and Barnard, J.J., The implantable cardioverter-defibrillator – a potential hazard for autopsy pathologists. Arch Pathol Lab Med, 121 (1997), 1076–1080.Google Scholar
O’Rear, J.M. and Prahlow, J.A., Early percutaneous endoscopic gastrostomy tube dislodgement. Am J Nursing, 115 (2015), 26–32.CrossRefGoogle Scholar
Prahlow, J.A., Prahlow, T.J., Rakow, R.J. and Prahlow, N.D., Case study: asphyxia caused by inspissated oral and nasopharyngeal secretions. Am J Nursing, 109 (2009), 38–43.Google Scholar
Batalis, N.I. and Prahlow, J.A., Accidental insulin overdose. J Forensic Sci, 49 (2004), 1117–1120.Google Scholar
Wikipedia [Internet]. San Francisco (CA): Wikimedia Foundation; 2017. “Angel of Mercy;” updated December 20, 2017. https://en.wikipedia.org/wiki/Angel_of_mercy_(criminology) (accessed December 20, 2017).Google Scholar
DiMaio, V.J. and DiMaio, T.G., Homicide by decubitus ulcers. Am J Forensic Med Pathol, 23 (2002), 1–4.Google Scholar
Collins, K.A. and Presnell, S.E., Elder neglect and the pathophysiology of aging. Am J Forensic Med Pathol, 28 (2007), 157–162.Google Scholar
Hanzlick, R., Hunsaker, J.C. and Davis, G.C., A Guide for Manner of Death Classification. (Savannah, MO: National Association of Medical Examiners, 2002).Google Scholar
Hanzlick, R. and Goodin, J., Mind your manners – part III: individual scenario results and discussion of the National Association of Medical Examiners manner of death questionnaire, 1995. Am J Forensic Med Pathol, 18 (1997), 228–245.Google Scholar
Hirsch, C.S. and Flomenbaum, M., Problem-solving in death certification. American Society for Clinical Pathology Check Sample, Forensic Pathology, FP95-1 (1995), 1–31.Google Scholar
Gill, J.R., Maloney, K.F. and Hirsch, C.S., The consistency and advantage of therapeutic complication as a manner of death. Acad Forensic Pathol, 2 (2012), 176–181.Google Scholar
Aiken, S.S., Bundock, E.A., Gunson, K.L. and Aiken, K., Death and dignity laws and the medical examiner. Acad Forensic Pathol, 5 (2015), 414–420.CrossRefGoogle Scholar
Heinemann, A., Vogel, H., Heller, M., Tzikas, A. and Puschel, K., Investigation of medical intervention with fatal outcome: the impact of postmortem CT and CT angiography. Radiol Med, 120 (2015), 835–845.Google Scholar
Weston, J.T., The medicolegal investigation of operating room associated deaths. Leg Med Annu (1977), 15–48.Google Scholar
Sens, M.A.. Air embolism demonstration. In Collins, K.A., ed., Special Autopsy Dissections (Northfield, IL: College of American Pathologists, 2010), pp 6–7.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×