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To the Editor.
—I have yet to see a report about a patient who gets cured as a result of a medical error. One case in my experience was that of a man with a pancreatic fistula that resulted from injuries sustained in a car accident. The fistula had not closed after two operations, and a third procedure had been planned. To that effect, the patient was sent to the radiology department for fistulography. The technician failed to dilute the radiopaque substance and proceeded to inject the concentrate into the fistula opening. It was caustic and thereby produced a chemical burn along the fistula tract. The fistula closed permanently and no operation became necessary. This occurrence could be called iatrogenic hamartiatria (Gr. hamartia "defect, sin "+ Gr. iatreia "healing") or simply a "curative error."
Berumen U. Iatrogenic Hamartiatria. JAMA. 1991;266(23):3284. doi:10.1001/jama.1991.03470230042019