A Trauma Case in the ED (Case #232)

• Medical Probability: 6 / 10
• Medical Error Summary: Hypotension in a trauma patient is a very ominous and not a common finding: it affects only 7% of patients presenting as trauma activation. Hypotension should have immediately triggered the highest le...
• Causation Probability: 6 / 10
• Causation Summary: Failure to get source control of bleeding leads to trauma coagulopathy with decreased fibrinogen, increased INR, increased PTT and decreased platelets. Once that coagulopthy ensues, it is a bit late ...
• Expert Summary: I am a trauma surgeon and intensivist with more than 18 years experience total and nearly 10 years experience in one of the busiest if not the busiest level 1 trauma centers in New England and the mai...
• Similar Summary: I see similar injury cases almost on a daily basis. In my safety and quality roles, I review cases with potential delays in recognition of severity on 2 to 3 times a month.

Laparoscopic Cholecystectomy with CBD and R Hepatic Artery injury (Case #325)

• Medical Probability: 10 / 10
• Medical Error Summary: This is a iatrogenic combined CBD and right hepatic artery injury. The most likely scenario is that the surgeon thought intraoperatively that they obtained the critical view of safety, but they were w...
• Causation Probability: 10 / 10
• Causation Summary: There was lack of situational awareness of what level the surgeon was working on, resulting in error in identification of the structures appropriately. While there might be risk factors that made this...
• Expert Summary: I have near 2 decades of experience in performing laparoscopic cholecystectomies (most common procedure I perform), as an acute care surgeon at the busiest and largest academic medical center in New E...
• Similar Summary: I do laparoscopic cholecystectomy nearly on a daily to weekly basis. I have not caused CBD injuries myself, but witnessed colleagues cause it, and also we are the referral center to manage these injur...

Stab wound, necrotizing fasciitis, death (Case #327)

• Medical Probability: 6 / 10
• Medical Error Summary: The key question in this case is whether an operative exploration with more thorough washout was needed at the initial presentation to the ED, especially that the kitchen knife possibly carried a sign...
• Causation Probability: 5 / 10
• Causation Summary: If there was an indication to do a more thorough evaluation of the stab wound with exploration and operative washout, there might be causation. This would be especially true if the stab wound had pene...
• Expert Summary: I have near 2 decades in experience as an acute care surgeon, have treated hundreds of stab wound and necrotizing skin and soft tissue infections at the largest academic medical center in New England....
• Similar Summary: I deal with stab wounds and necrotizing skin and soft tissue infections on a daily to weekly basis.

Bilateral hernia mesh placement with complications (Case #337)

• Medical Probability: 5 / 10
• Medical Error Summary: A key element of this case is the fact that the operative report of the case specifies that there was a cord lipoma that was reduced from the internal ring. As such, whether this was true or not, this...
• Causation Probability: 5 / 10
• Causation Summary: Mesh can cause problems even when there is no clear error occurring. These problems could be infections or nerve pain. Recurrence can also occur. I am not sure I see there is clear causation from the ...
• Expert Summary: I do inguinal hernia repair as part of my practice in a large busy academic hospital, and have published a few articles related to inguinal hernia. I am a nationally recognized authority in patient sa...
• Similar Summary: yes, related to inguinal hernia complications

Death from shock and multi-organ failure after motorcycle accident (Case #341)

• Medical Probability: 5 / 10
• Medical Error Summary: THis is a complex critical polytrauma case. Contrast can have iodine, but it is more likely than not that the shock is resultant of the very high severity of injury that can cause distributive shock d...
• Causation Probability: 5 / 10
• Causation Summary: There are enough reasons to explain the shock. Swelling of the face is not uncommon after major fluid resuscitation. The question rather should be whether the contrast might have contributed rather th...
• Expert Summary: I am a trauma surgeon and surgical intensivist in one of the busiest and largest level 1 trauma centers in New England, an Associate Professor of Surgery at Harvard Medical School and a well known aut...
• Similar Summary: I take care of trauma patients on a daily basis in a busy level 1 trauma center. Blunt trauma like a motorcycle crash is the predominant mechanism of injury I see.

54 y.o. man dies of hemorrhagic shock after laparoscopic Roux-en-Y gastric bypass (Case #354)

• Medical Probability: 6 / 10
• Medical Error Summary: A patient who presented with hypotension and tachycardia needed urgent intervention with either the endoscopy or surgery, but the details matter in terms of how the patient responded to initial resusc...
• Causation Probability: 6 / 10
• Causation Summary: If there is delay in intervention, this could have contributed to the eventual poor outcome and death.
• Expert Summary: I am an acute care surgeon with more than 12 years of attending experience at one of the busiest and largest teaching hospitals of the Northeast. I have seen and managed many similar patients. In addi...
• Similar Summary: I take care of similar cases several times a year. I take care of septic shock and hemorrhagic shock patients on a daily basis.

Failure to properly monitor patient for potential bowel perforation following MVA and discharging early. (Case #421)

• Medical Probability: 6 / 10
• Medical Error Summary: Hollow viscus injuries in the setting of trauma, especially blunt trauma are tricky as one needs to rely on two things to decide on exploration of the abdomen: 1. Abdomen exam (e.g. signs of peritonit...
• Causation Probability: 6 / 10
• Causation Summary: There is no causation as to the injury, but there is likely delay in recognition of the injury and decision to operate or transfer for operation. Those CT imaging findings were very concerning for fho...
• Expert Summary: 1. I am an attending trauma surgeon with a total of 21 years of surgical experience, 12 of which as an attending surgeon at the busiest trauma center in the New England area (MGH), a level 1 universit...
• Similar Summary: I encounter similar cases directly or for review every week.

Patient with history of prior abdominal surgery, dies during laparoscopic procedure. End tidal co2 dropped immediately after a Veress needle was inserted into the peritoneum. (Case #452)

• Medical Probability: 6 / 10
• Medical Error Summary: More detailed review of the operative and anesthesia record is needed, but my concern is for the veress needle to have caused a left sided tension pneumothorax that led to decreased end tidal CO2. Tha...
• Causation Probability: 6 / 10
• Causation Summary: If the veress needle did indeed cause a tension pneumothorax, this is a iatrogenic injury. More importantly, the surgical team should have placed a left sided chest tube, even if the diagnosis is not ...
• Expert Summary: I am trauma and acute care surgeon with a total of 22 years of experience (counting surgical training years). I work in one of the busiest, largest and most reputable academic medical centers in the c...
• Similar Summary: Weekly between my two roles, clinical and administrative

Review by board certified critical care surgeon for delayed compartment syndrome diagnosis and treatment of right foot. (Case #526)

• Medical Probability: 6 / 10
• Medical Error Summary: 1. Compartment syndrome of the foot is a difficult diagnosis with specialized management often left to the foot and ankle orthopedic specialists rather than trauma surgeons or general orthopedic surge...
• Causation Probability: 6 / 10
• Causation Summary: see above response, #3 has the details
• Expert Summary: I am a trauma surgeon who deals with compartment syndrome of the extremities and abdomen on a weekly basis and make the judgment of diagnosis and whether to offer surgery or not on a weekly basis. I w...
• Similar Summary: weekly- very often. I also review cases if there is suspicion of delays in care on a daily basis