In 2001, my grandfather, who had a longstanding history of Parkinson’s Disease, was hospitalized for knee surgery. Post-surgically, he was given Haldol, presumably for post-op nausea and vomiting. Haldol, a potent dopamine blocker, is not to be administered to Parkinson’s patients under any circumstances. He began to experience severe paranoia and hallucinations, convinced that the hospital staff was a cult that was holding him hostage, as well as worsening Parkinson’s symptoms. He tried to convince my mother to help him escape, and talked incessantly about “Sylvia,” a demon lamp in the corner of his room that was after him. One night, he was found wandering on a different floor of the hospital; he had yanked out his IVs and attempted to escape “the cult.” After several bizarre and disconcerting days of erratic behavior and worsening dyskinesias, he was taken off of Haldol, and returned to full health.

I am grateful that none of my family or friends have been victims of medical error on the tragic level of Lewis Blackman and many others. That being said, I feel that the remarkable thing about this incident was that it was several days before this error was discovered, and my grandmother was the one who figured it out herself. In addition, no apology was issued by any members of the healthcare team, and no follow up was performed by the hospital with my family. I was young when this happened, but after interviewing my grandmother and reflecting on several other cases of medical error, I began to see a pattern: error, adverse outcomes, and either action or apology or a lack thereof. But what occurs before this error? In order to facilitate a reduction in medical error, we must be proactive rather than reactive, and to do so, we have to trace back to the root of the problem. What does this event tell us about communication, healthcare team dynamics, EMR, accessibility of information, the hierarchical nature of the medical profession? My grandfather had been a Parkinson’s patient at this same medical institution for 16 years when this occurred – how did this information get overlooked? Where is the breakdown?