Case Results

Issue

Delayed C-section resulting in HIE

Summary

Failure to recognize fetal distress and delay in performing emergency cesarean delivery resulted in hypoxic-ischemic encephalopathy and subsequent cerebral palsy diagnosis.

Issue

Erb's palsy from shoulder dystocia

Summary

Improper management of shoulder dystocia during delivery resulted in brachial plexus injury and permanent Erb's palsy in the newborn.

Issue

Failure to monitor fetal heart rate

Summary

Hospital staff failed to properly interpret Category III fetal heart rate tracings, resulting in delayed intervention and neonatal brain injury.

Issue

Pitocin overdose causing uterine rupture

Summary

Excessive administration of Pitocin during labor led to hyperstimulation and uterine rupture, resulting in hypoxic brain injury to the infant.

Issue

Neonatal stroke from delivery trauma

Summary

Traumatic forceps delivery caused neonatal arterial ischemic stroke, resulting in long-term neurological deficits.

Issue

Wrong-site orthopedic surgery

Summary

Surgeon operated on the wrong extremity despite surgical timeout protocols, requiring additional corrective surgery.

Issue

Retained surgical object

Summary

Surgical sponge was left in the patient's abdominal cavity, causing infection and requiring a second operation for removal.

Issue

Bowel perforation during laparoscopy

Summary

Surgeon perforated the bowel during a laparoscopic procedure and failed to recognize the injury intraoperatively, leading to peritonitis and sepsis.

Issue

Nerve damage during spinal fusion

Summary

Negligent placement of pedicle screws during spinal fusion surgery damaged nerve roots, resulting in permanent lower extremity weakness.

Issue

Post-operative hemorrhage

Summary

Failure to achieve adequate hemostasis during surgery led to post-operative hemorrhage requiring emergency reoperation and blood transfusions.

Issue

Ureter injury during hysterectomy

Summary

Surgeon inadvertently transected the ureter during a robotic hysterectomy, which was not recognized intraoperatively, leading to kidney damage.

Issue

Delayed diagnosis of breast cancer

Summary

Radiologist failed to identify a suspicious mass on mammogram, resulting in a 14-month delay in cancer diagnosis and disease progression from Stage 1 to Stage 3.

Issue

Missed stroke diagnosis in ER

Summary

Emergency department failed to recognize stroke symptoms in a young patient, delaying treatment beyond the tPA window and resulting in permanent disability.

Issue

Failure to diagnose aortic dissection

Summary

ER physicians misattributed chest pain to musculoskeletal causes and discharged the patient, who suffered a fatal aortic rupture hours later.

Issue

Delayed sepsis diagnosis

Summary

Failure to initiate the sepsis protocol in a timely manner resulted in septic shock, multi-organ failure, and permanent kidney damage.

Issue

Missed colon cancer on colonoscopy

Summary

Gastroenterologist failed to identify a visible tumor during screening colonoscopy, resulting in an 18-month delay in cancer diagnosis.

Issue

Failure to diagnose pulmonary embolism

Summary

Patient presenting with shortness of breath and chest pain was discharged with a diagnosis of anxiety. The patient suffered a fatal pulmonary embolism the following day.

Issue

Failure to monitor post-operative patient

Summary

Hospital staff failed to monitor a post-operative patient's deteriorating vital signs, resulting in cardiac arrest and death that was preventable with timely intervention.

Issue

Fatal medication overdose in ICU

Summary

ICU nurse administered a fatal dose of medication due to a decimal point error, resulting in the patient's death.

Issue

Untreated hospital-acquired infection

Summary

Hospital failed to diagnose and treat a hospital-acquired infection in a timely manner, resulting in sepsis and the patient's death.

Issue

Failure to diagnose appendicitis

Summary

Emergency department discharged a patient with a misdiagnosis of gastroenteritis. The patient's appendix ruptured, leading to peritonitis and death.

Issue

Heparin overdose in neonatal ICU

Summary

NICU staff administered a 1000-fold heparin overdose to a premature infant due to a labeling and verification failure, causing intracranial hemorrhage.

Issue

Wrong drug dispensed by pharmacy

Summary

Pharmacy dispensed the wrong medication to a patient, who suffered an adverse reaction requiring hospitalization.

Issue

Insulin dosing error

Summary

Hospital staff administered an incorrect insulin dose, resulting in severe hypoglycemia and permanent brain injury.

Issue

Failure to check drug interactions

Summary

Physician prescribed a contraindicated drug combination, resulting in serotonin syndrome and ICU admission.

Issue

Anticoagulant dosing error

Summary

Improper management of warfarin therapy resulted in a life-threatening gastrointestinal hemorrhage.

Issue

Anesthesia awareness during surgery

Summary

Patient experienced anesthesia awareness during surgery due to insufficient anesthetic dosing, resulting in PTSD and psychological trauma.

Issue

Hypoxic brain injury from intubation failure

Summary

Anesthesiologist failed to properly intubate the patient, resulting in prolonged hypoxia and permanent brain damage.

Issue

Spinal epidural hematoma

Summary

Improper placement of an epidural catheter resulted in a spinal epidural hematoma causing permanent paralysis.

Issue

Failure to monitor during sedation

Summary

Anesthesia provider failed to properly monitor a patient during procedural sedation, resulting in respiratory arrest.

Issue

Failure to prevent hospital-acquired infection

Summary

Hospital failed to follow infection control protocols, resulting in a patient acquiring a serious MRSA infection that required prolonged treatment.

Issue

Hospital fall resulting in traumatic brain injury

Summary

Hospital staff failed to implement fall precautions for a high-risk patient, resulting in a fall and traumatic brain injury.

Issue

Failure to escalate deteriorating patient

Summary

Nursing staff failed to activate a rapid response team for a patient showing clear signs of deterioration, resulting in cardiac arrest.

Issue

Premature discharge of unstable patient

Summary

Patient was discharged from the ER despite unstable vital signs, and suffered a cardiac event at home requiring emergency re-admission.

Issue

Misread chest X-ray missing lung cancer

Summary

Radiologist failed to identify a visible lung nodule on a chest X-ray, resulting in a two-year delay in cancer diagnosis.

Issue

Failure to communicate critical CT finding

Summary

Radiology department failed to communicate a critical finding on a CT scan to the ordering physician, resulting in delayed treatment.

Issue

Missed brain hemorrhage on CT scan

Summary

Radiologist misread a head CT as normal when it showed an acute subarachnoid hemorrhage. The patient deteriorated and suffered permanent brain damage.

Issue

Failure to compare prior imaging studies

Summary

Radiologist failed to compare current imaging with prior studies, missing a growing tumor that was visible on comparison.

Issue

Stage IV pressure ulcers

Summary

Nursing home failed to implement pressure ulcer prevention protocols, resulting in the development of multiple Stage IV bedsores and sepsis.

Issue

Nursing home fall and hip fracture

Summary

Facility failed to implement a fall prevention plan for a known fall risk, resulting in a hip fracture and surgical complications.

Issue

Severe malnutrition and dehydration

Summary

Nursing home staff failed to monitor the resident's nutritional intake, resulting in severe malnutrition, dehydration, and hospitalization.

Issue

Failure to prevent elopement

Summary

Nursing home failed to secure exits for a resident with dementia who eloped and was found injured outside the facility.

Issue

Defective hernia mesh causing chronic pain

Summary

Patient implanted with defective hernia mesh suffered chronic pain, infection, and required revision surgery to remove the mesh.

Issue

Dangerous drug causing kidney injury

Summary

Patient prescribed a medication with inadequate warnings suffered acute kidney injury requiring dialysis.

Issue

Defective IVC filter migration

Summary

IVC filter migrated and perforated the patient's vena cava, requiring emergency surgery to remove.

Issue

Robotic surgery device malfunction

Summary

Malfunction of a robotic surgical system during procedure caused thermal injury to surrounding tissues.