If there's any question that the people in charge of the state's adverse events report need to get a better grip on what exactly counts as a medical mistake, take a look at the case of David Croud.
On Oct. 18, 2005, Croud, 29, died at St. Mary's Duluth Clinic. Six days earlier he had been arrested by police who took him to the hospital with a blood-alcohol content of 0.31 percent.
A St. Louis County medical examiner determined the cause of death as a lack of oxygen to his brain due to "acute alcohol intoxication and Haldol administration.'' Haldol, an antipsychotic commonly used to treat agitated patients, was given to Croud at St. Mary's.
So was the death an adverse event? The list of reportable events does include "death [or] serious harm from a drug error." But Special Investigator Pat FitzGibbons of the Minnesota Department of Health questioned that possibility, issuing a Nov. 14, 2005, report that stated it "could not be fully determined" that the dose of Haldol caused Croud's death.
Another reportable event on the list is "death [or] serious harm from the use or lack of restraints or bedrails."
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FitzGibbons reported that "hospital staff did not adequately intervene to position the patient on his back or side, to request that his handcuffs be removed, and that four point cloth restraints be placed, at the time of admission or when the patient calmed down."
All of the above would indicate that the incident would meet at least one of the adverse event standards; if not a medical error, then it would certainly fit the category of "use or lack of restraints."
To its credit, St. Mary's staff reported the incident to the state as an adverse event.
"We did make the Minnesota Hospital Association aware of this death, and we did, of course, report it to the Minnesota Department of Health and the joint commission. Both investigated fully," St. Mary's spokeswoman Kim Kaiser told the News Tribune yesterday.
Yet the hospital later recalled that report, Kaiser said. "At the time we reported Mr. Croud's death, [we] ... simply had not had enough time to complete our investigation," she said.
Once that investigation was complete, the hospital's opinion changed. It no longer viewed the medication or restraint issues as possible causes of death. Despite FitzGibbons' report and findings similar to his by the St. Louis County medical examiner, the state Department of Health agreed.
"The hospital felt that the death was not related to the use of restraints. The Department of Health agreed with that conclusion," Diane Rydrych of the department's Office of Health Policy, Statistics and Informatics told the News Tribune. She did not discuss the Haldol issue, which presumably also was dismissed as a factor in the death.
Assuming the Department of Health's decisions are supported by sound medical scrutiny, those conclusions are fine -- except for one gnawing fact:
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David Croud died.
It was clearly accidental.
And if the 27 standards defining a mistake aren't enough to explain it, the standards should be re-examined, or expanded to include a new category called "Other."
Maybe Croud's tragic death could not appropriately be categorized as an adverse event. But taking him off the list didn't bring him back to life.
