Delayed diagnosis of colon cancer with signet ring cell features (Case #275)

• Medical Probability: 4 / 10
• Medical Error Summary: There is 5% cancer miss rate (esp right sided lesions) even with high quality colonoscopy, this exam appeared to be complete to the cecum, in a well prepped colon and the recall interval based on find...
• Causation Probability: 3 / 10
• Causation Summary: See above. There is 5% cancer miss rate (esp right sided lesions) even with high quality colonoscopy, this exam appeared to be complete to the cecum, in a well prepped colon and the recall interval ba...
• Expert Summary: I have performed over 10,000 colonoscopies and my expertise is GI cancer detection.
• Similar Summary: Once a year on avg, it is a limitation of the procedure itself even under the best of circumstances. See: https://www.gastrojournal.org/article/S0016-5085(04)00924-2/fulltext

Death due to hypotensive shock, severe blood loss, and acute GI bleed. (Case #296)

• Medical Probability: 8 / 10
• Medical Error Summary: See below Was the pt appropriately in the ICU post EGD? Was there a plan for follow up hemoglobin? Is it true that no one tried to reach the physician until four hours after there was a change in ...
• Causation Probability: 8 / 10
• Causation Summary: Was the pt appropriately in the ICU post EGD? Was there a plan for follow up hemoglobin? Is it true that no one tried to reach the physician until four hours after there was a change in vital signs ...
• Expert Summary: 17 years of practice in endoscopy including interventional training
• Similar Summary: Never had a hospitalized patient exsanguinate under my watch but it (rarely) happens

Possible failed biopsy via endoscopy resulting in perforated bowel w/ multiple complications and rapid decline in patient's condition. (Case #366)

• Medical Probability: 5 / 10
• Medical Error Summary: The problem here is that perforation is a known complication, so it would depend on the nature of the indication for the procedure, and whether or not, there was gross negligence, which could be hard ...
• Causation Probability: 6 / 10
• Causation Summary: Seems clear that the perforation led to his demise, see above. It appears there is adequate documentation of this perforation, and that it was recognized in a timely fashion. The problem here is th...
• Expert Summary: Interventional endoscopist/academic The problem here is that perforation is a known complication, so it would depend on the nature of the indication for the procedure, and whether or not, there was...
• Similar Summary: Often The problem here is that perforation is a known complication, so it would depend on the nature of the indication for the procedure, and whether or not, there was gross negligence, which could...

General Surgeon With Upper GI Bleed Requesting Urgent Upper Scope To Be Told By GI To Place Patient In ICU Until The Morning. (Case #409)

• Medical Probability: 5 / 10
• Medical Error Summary: Complicated case. While the delayed return call from the G.I. team is not a good look and they may have violated internal hospital policy, ultimate ownership of the patient belongs to what sounds like...
• Causation Probability: 6 / 10
• Causation Summary: Complicated case. While the delayed return call from the G.I. team is not a good look and they may have violated internal hospital policy, ultimate ownership of the patient belongs to what sounds like...
• Expert Summary: 20 years of hospital based GI experience
• Similar Summary: Fairly frequently 3-4 per year

74yo F splenic laceration during a colonoscopy with polypectomy (Case #481)

• Medical Probability: 5 / 10
• Medical Error Summary: Generally speaking, splenic laceration is an under recognized complication of even routine colonoscopy. It can be hard to diagnose and can present in a delayed fashion. The main aspect to review with ...
• Causation Probability: 5 / 10
• Causation Summary: see above, the medical team can do everything right and yet still this diagnosis can be missed given the opportunity for a delayed presentation, and inability to visualize any potential injury at the ...
• Expert Summary: 20 years of experience doing both routine and advanced endoscopy, my experience as Medical Director for a large ambulatory surgical center in Manhattan and my review of both inpatient and outpatient e...
• Similar Summary: A few times per year, as mentioned, this is probably undiagnosed in many of our practices, but when it is missed the results can be quite catastropihc.

Internal bleed resulting in death (Case #489)

• Medical Probability: 4 / 10
• Medical Error Summary: Sounds like the ulcer was in a difficult position for other hemostatic options and they did apply two methods for this high risk lesion, which is generally speaking the standard of care. I’m assumin...
• Causation Probability: 4 / 10
• Causation Summary: See above. If there was any evidence of ongoing bleeding after the initial endoscopy, then additional methods and or approaches should have been applied, but that would depend on a review of the recor...
• Expert Summary: 20 years of clinical experience
• Similar Summary: It is extremely rare to bleed to death in an inpatient setting, but it can happen.

Failure to diagnosis perforation in sigmoid colon leading to extensive leakage of fecal matter into abdominal and requiring surgery. (Case #512)

• Medical Probability: 5 / 10
• Medical Error Summary: Initial management for uncomplicated diverticulitis includes antibiotics, or in some cases no antibiotics, but no specific recommendation for management of stool burden. Unless evidence of perforation...
• Causation Probability: 5 / 10
• Causation Summary: Initial management for uncomplicated diverticulitis includes antibiotics, or in some cases no antibiotics, but no specific recommendation for management of stool burden. Unless evidence of perforation...
• Expert Summary: 20 years in general Gastroenterology, practice, board certification, full time academic teaching hospital environment
• Similar Summary: Diverticulitis or the concern for diverticulitis is a very common complaint. I probably see a few patients every month with such concerns.

57yo M Colonoscopy Complicated by Perforated Viscus (Case #546)

• Medical Probability: 6 / 10
• Medical Error Summary: While this appears to be an indicated procedure, there are a few findings in the report that call into question, whether or not the use of hot biopsy forceps, which have a known higher risk of perfora...
• Causation Probability: 6 / 10
• Causation Summary: see above The use of electrocautery is associated with a higher risk of bowel wall injury, and perforation, and needs to be applied selectively and with caution. This is likely the mechanism of inj...
• Expert Summary: 20 years of endoscopy and colonoscopy experience, including advanced training in interventional, endoscopy and familiarity with all of the techniques used in this case.
• Similar Summary: The need to remove polyps at colonscopy is a routine matter in my practice.

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

• Medical Probability: 7 / 10
• Medical Error Summary: Acute pancreatitis has a broad spectrum of disease severity that can defy clinical predictor models, but there are fundamental common sense practices that are universal. Without access to primary sour...
• Causation Probability: 6 / 10
• Causation Summary: Acute pancreatitis has a broad spectrum of disease severity that can defy clinical predictor models, but there are fundamental common sense practices that are universal. Without access to primary sour...
• Expert Summary: 20 years of experience as a practicing gastroenterologist at an academic teaching hospital, including inpatient inpatient management of acute and chronic pancreatitis
• Similar Summary: Cases of this severity come up a few times each year