Massive DVT resulting in death (Case #181)

• Medical Probability: 7 / 10
• Medical Error Summary: Although there is not enough information to make a clear judgement form the case, the patient's history of cancer and recent surgery, the lack of other history to explain a sudden dyspnea exacerbation...
• Causation Probability: 7 / 10
• Causation Summary: Based on the above justification, prompt PE/DVT diagnosis would have resulted in anticoagulation and/or IVC filter placement, depending on the postoperative bleeding risk. Any of those interventions c...
• Expert Summary: I am surgical intensivist and, therefore, I see cases such as these frequently. Furthermore, I work as a surgical intensivist in an orthopedic hospital, where the incidence of DVT/PE is very high. I h...
• Similar Summary: As described above, I frequently encounter similar cases.

Delay in diagnosis and treatment of ANCA-associated vasculitis (Case #292)

• Medical Probability: 8 / 10
• Medical Error Summary: I believe a medical error led to a delay of three days in drawing ANCA serologies. The principal error was the serology cancellation without apparent notification to the providers. It is important to ...
• Causation Probability: 5 / 10
• Causation Summary: It is unclear whether a delay of three days, during which the patient received steroids, led to permanent organ damage or significantly prolonged mechanical ventilation. I would not be confident to st...
• Expert Summary: I have practiced in hospitals specializing in autoimmune disorders during my training. I currently work as an intensivist in a major academic institution.
• Similar Summary: Currently, infrequently, less than once a year

Delay in Diagnosis and Treatment of Herpes Encephalitis (Case #306)

• Medical Probability: 9 / 10
• Medical Error Summary: Herpetic encephalitis is clearly in the differential diagnosis of fever and confusion. Accordingly, the ER physician suspected the diagnosis and initiated empiric treatment. When the treating physicia...
• Causation Probability: 9 / 10
• Causation Summary: It also very likely that the delay contributed to the patient's permanent neurologic damage, as time is of the essence in treating HSV encephalitis. Because the patient consulted within the first day ...
• Expert Summary: I am an intensive care physician, and have practiced as a hospitalist. I work within the scope of practice of the involved physicians, Involving an ID physician as well can provide further support fo...
• Similar Summary: Herpetic encephalitis is a rare condition. As such, I infrequently see cases such as this one (less than once a year). That being said, physicians are trained to recognize infrequent but severe condit...

49yo Male Hx of COPD, Dx large bullous lesion. Concern about follow up/surveillance care. (Case #451)

• Medical Probability: 4 / 10
• Medical Error Summary: The bullous emphysema does not require CT imaging follow-up unless he patient becomes symptomatic, such as developing a pneumothorax. Because the patient is younger than 50 years old now, he did not ...
• Causation Probability: 4 / 10
• Causation Summary: There was no indication for imaging follow-up based on the information provided. However, the 2023 CT report may have missed a lung nodule. A radiologist should review that imaging.
• Expert Summary: I am a pulmonary critical care Board-certified physician trained at a reputable institution (Mayo Clinic)
• Similar Summary: I see similar cases on a monthly basis

Patient did well after surgery. 3 days later CT showed massive aspiration. Plastic found in left bronchi. Died two weeks later of hypoxic respiratory failure. (Case #458)

• Medical Probability: 6 / 10
• Medical Error Summary: More information is needed about this case since multiple, scantly described events were brought up. I believe a full chart review is necessary to make an accurate determination. I am inclined to th...
• Causation Probability: 6 / 10
• Causation Summary: If the points I described above (plastic aspiration, calling off the RRT, rejection of DNR reversal) are true, there could be causation. However, more information is needed
• Expert Summary: I am an experienced surgical critical care physician who deals with similar cases on a daily basis. I have led many surgical critical care quality improvement initiatives. I trained and work in reputa...
• Similar Summary: On a daily basis. I work in surgical intensive care

Potential improper prescription for steroids given history of aortic aneurysm. (Case #573)

• Medical Probability: 6 / 10
• Medical Error Summary: Although the case presentation focuses on whether the indication for steroids was appropriate, I would point more towards the diagnosis, follow-up, and treatment of the known thoracic aortic aneurysm ...
• Causation Probability: 6 / 10
• Causation Summary: It appears that the cause of death was a dissecting aortic aneurysm. The patient did not have these symptoms during the telephone consultation. I therefore do not think that having been seen at the of...
• Expert Summary: I think the best expert would be a cardiologist or a cardiovascular surgeon.
• Similar Summary: I encounter patients with aortic aneurysm repairs frequently after surgery, and I am accustomed to their care. I also encounter patients with reactive airway disease, and I have indirect exposure to p...

Potential negligent treatment of acute pancreatitis resulting in multiorgan failure. (Case #575)

• Medical Probability: 6 / 10
• Medical Error Summary: There appear to be a few medical errors, such as insufficient monitoring on a general ward vs ICU, due to the lack of correct severity assessment. Chart review could explain better why the Htc increas...
• Causation Probability: 5 / 10
• Causation Summary: The course appears typical of severe pancreatitis, which oftentimes evolves in this way despite optimal management. Some of the issues pointed out, such as using NS instead of LR, are unlikely to have...
• Expert Summary: I have been a critical care specialist for 25 years and have been practicing surgical critical care for 16 years, giving me a unique positioning amongst intensivists to understand surgical indications...
• Similar Summary: Although pancreatitis of this severity is rare overall, given my practice in surgical critical care, I may see a concentrated amount of these cases, roughly 5-7 /year, between my SICU and MICU practic...

57yo MRSA Vertebral Osteomyelitis, Septic Shock, Cardiac Arrest, and Hypoxic Brain Injury (Case #588)

• Medical Probability: 7 / 10
• Medical Error Summary: Since there was more prominent weakness of the lower extremities, imaging of the spine should have been repeated and Neurosurgery consulted, especially if there also was a sensory deficit (unclear fro...
• Causation Probability: 7 / 10
• Causation Summary: It appears that the error is likely to have caused possible irreversible neurologic injury. However, the link between the error and death is less clear, and further review is necessary to determine wh...
• Expert Summary: I think the best experts for this case are a neurosurgeon, and ID. Critical Care, my specialty can help clarify the workflow and coordination and the treatment of sepsis later on. If Critical Care is ...
• Similar Summary: I encounter similar cases on a weekly basis