MedMal Insider

When a speech and swallowing evaluation showed the patient to be at risk for aspiration, the resident documented a plan that the patient be given nothing by mouth. But the NPO order was not entered into the system, a technician attempted to feed him, and he aspirated. This was not communicated to the attending. After transfer to the ICU, he succumbed to additional morbidities, including aspiration pneumonia.

When a patient returns over and over again with the same symptom complex, the providers really need to start to think, "am I missing something?"

A 26-year-old male presented to the emergency department with burning chest pain. After two more visits within four days for the same complaint, he died at home from acute coronary thrombosis. Did the clinicians’ frustration with the course of his condition lead them to blame the patient rather than reconsider their diagnosis?

Fixated on flu symptoms, the nurse missed available information that indicated the patient should have been brought to urgent care to prevent an unnecessary tragedy.

A father called his son's pediatrician’s office on a winter week-end night and told the nurse practitioner that his nine-year-old had not felt well for three days. The nurse fixated on flu symptoms and told the father to push ginger ale. When the father checked on the boy 12 hours after the call, he had died from diabetic ketoacidosis and his diabetes mellitus was undiagnosed until autopsy.

The patient had a history of suicidality when her psychiatrist referred her to a sleep specialist. Three weeks after the second doctor increased her oxycodone dose to treat restless leg syndrome, the patient used the drug to kill herself.

In this case, an 8-year-old girl experienced a tenfold dosing error of clotting factor, requiring admission and observation due to increased risk of stroke. It could be said that the culture at this hospital both contributed to the error, and contributed to a good response by staff.

An 8-year old girl was treated over three years for a condition she never had. Multiple providers missed a test result that showed she had celiac disease, so it went untreated and she suffered. The resulting lawsuit resulted in a settlement against two of her doctors. This case study not only reviews the facts, but it also features suggestions from an expert reviewer on how to prevent similar mistakes managing test results.

A presumptive diagnosis during an office visit kept the doctor from broadening the differential to include a much more serious condition. Commentator Carla Ford, MD says, “These are the kinds of situations that our primary care providers and urgent care providers are faced with all the time.”

Fetal bradycardia forced an emergency C-section, but the family claimed the care team should have been more prepared.