37-year-old death from delayed stroke after car accident (Case #260)

• Medical Probability: 7 / 10
• Medical Error Summary: When there is a change in mental status in a victim of blunt trauma (especially one where there was loss f consciousness) and there is a normal CT head and neck, a CT angio of the neck should be done ...
• Causation Probability: 7 / 10
• Causation Summary: the lack of timely cerebral vascular imaging after neurologic symptoms developed resulted in the delay of ASA dosing and this delay may have caused the poor outcome
• Expert Summary: I have 13 years of experience in a busy level one trauma center and I am board certified in general surgery and surgical critical care.
• Similar Summary: we care for blunt cerebral vascular injury or patients with the potential of BCVI several times per week

Colon perforation while inpatient (Case #316)

• Medical Probability: 9 / 10
• Medical Error Summary: Physical exam findings were not documented in the written scenario which is critically important to the management of this patient. If there was peritonitis present on exam, regardless of CT findings...
• Causation Probability: 9 / 10
• Causation Summary: This patient had very clear evidence of worsening sepsis and a known very likely source in the abdomen based on the CT report. She needed urgent evaluation by surgery and exploratory laparotomy for s...
• Expert Summary: I am board certified in general surgery and surgical critical care. I work at a very busy verified level one trauma center and I have an academic appointment at the local medical school I have 17 yea...
• Similar Summary: I see and manage patients with sepsis related to surgical diagnoses similar to this patient on a weekly basis. I manage both their operative and critical care needs.

Death after tracheostomy (Case #320)

• Medical Probability: 9 / 10
• Medical Error Summary: With each tracheostomy placement, it is encumbrance on the treatment team to ensure that appropriate cuff pressure is checked and documented. It seems that in this case, there was an issue with trach...
• Causation Probability: 9 / 10
• Causation Summary: Because the cuff pressure was not monitored on a daily basis (as is done in many hospitals, including the hospital where I am on staff), it is difficult to know how much pressure is in the cuff. The ...
• Expert Summary: I have 14 years of experience as a trauma surgeon at a verified level one trauma center. In my hospital, trauma surgeons are tasked with tracheostomies and we do several per month.
• Similar Summary: We see several complex tracheostomy cases per month with head and neck cancer and traumatic wounds. Given the importance of the airway in a resuscitative setting, I am required to do emergent surgica...

No Surgery for Abdominal Bleed (Case #321)

• Medical Probability: 8 / 10
• Medical Error Summary: There are several concerns about this case. First, the surgeon should have seen the patient when called. Rectus sheath hematomas can be difficult to treat surgically given the difficulty of find the...
• Causation Probability: 8 / 10
• Causation Summary: The lack of checking anti Xa in this patient and the delay in surgical input and resuscitation direction by the surgeon very likely contributed to the bad outcome. It does not say specifically that t...
• Expert Summary: I have 14 years of experience in trauma and acute care surgery at a busy verified level one trauma center and I am director of the acute care surgery section or our department of surgery.
• Similar Summary: We see rectus sheath hematomas several time per year. Most of them can be managed non-operatively, or with interventional radiology. In the case of hemorrhagic shock as in this case, urgent surgical...

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

• Medical Probability: 10 / 10
• Medical Error Summary: Interesting case. There is literature that describes accessory ducts, but I have never seen one. It is clear that structures were misidentified during surgery. When one describes that a critical vie...
• Causation Probability: 10 / 10
• Causation Summary: No cholangiogram was done prior to dividing the structures. A cholangiogram would have shown the anatomy and avoided common hepatic duct injury
• Expert Summary: For 14 years ongoing, I have worked at a busy verified level one trauma center where I cover trauma and acute care surgery, while serving as the medical director of acute care surgery. I am board cer...
• Similar Summary: My service does all of the acute gall bladder surgery at a busy 800 bed hospital. We see many challenging gall bladders and attend to their operative and non-operative management

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

• Medical Probability: 10 / 10
• Medical Error Summary: I have several areas of concern. First, I would not have closed the stab wound at the initial visit. It was not mentioned that there was imaging done at the first visit to rule out vascular or other...
• Causation Probability: 10 / 10
• Causation Summary: This infection is a surgical disease. Antibiotics can help the tissue that still has blood flow, but the necrotic tissue must be surgically debrided emergently, and a second look operation is critical...
• Expert Summary: For the last 14 years ongoing, I am a trauma and acute care surgeon at a bust verified level one trauma center. I serve as the acute care surgery medical director for the facility. We are a tertiary...
• Similar Summary: Many times per year. I manage the initial resuscitation, surgical debridement and post op ICU care

Bilateral hernia mesh placement with complications (Case #337)

• Medical Probability: 10 / 10
• Medical Error Summary: The presence of a cord lipoma does indicate the presence of a hernia. It is stated in the dictation that the peritoneum did not traverse the inguinal ring which indicated that no hernia was present ev...
• Causation Probability: 10 / 10
• Causation Summary: It is not stated what the specific complications were but if mesh was placed to fix a nonexistent hernia, then any complications related to the mesh could have been avoided by not placing it.
• Expert Summary: I am board certified in general surgery and critical care and serve as the medical director for acute care surgery at a verified level one trauma center. I do many elective and emergent inguinal herni...
• Similar Summary: I frequently see elective and emergent inguinal hernias and complications related to previous inguinal surgery. I address these complications with mesh removal or an occasional neurectomy for intracta...

Bedside tracheostomy has multiple complications including esophageal perforation and repair procedures. (Case #372)

• Medical Probability: 10 / 10
• Medical Error Summary: There is concern on many fronts with this case. It is recommended that there be a provider who is monitoring the sedation in addition to the proceduralist. This would have allowed immediate help and...
• Causation Probability: 10 / 10
• Causation Summary: It is clear based the documentation offered that an esophageal injury occurred during the course of the procedure. This is a known complication for this procedure. The delay in repairing the injury ...
• Expert Summary: I am professor of surgery at a busy verified level one trauma center. I work in a high-volume practice and open and percutaneous tracheostomy is a very common procedure for me.
• Similar Summary: I deal with challenging airways as a significant part of my practice. I am aware of the potential complication with airway procedures, especially in the setting of other injuries that may distort the...

Young male needs CVC for sickle cell treatment, surgeon perforates subclavian artery bedside, has multiple complications (Case #376)

• Medical Probability: 7 / 10
• Medical Error Summary: This is a difficult case to evaluate. It is reported that an ultrasound was used which is the standard of care, but, if used properly (meaning that the U/S image shows the needle entering the IJ in r...
• Causation Probability: 7 / 10
• Causation Summary: Sere my above response. I think that if used properly, an ultrasound guided placement in the right IJ would be standard of care, but it seems that is would be very unlikely to damage the subclavian a...
• Expert Summary: I am board certified in general surgery and critical care. I have 18 years of post-residency experience at a busy verified level on trauma facility. I am the medical director of the acute care surge...
• Similar Summary: We put in several central lines per week and do see patients with sickle cell anemia. I am very adept at placing central venous access in elective and urgent situations and also managing complication...

Injury to the aorta inferior mesenteric vein, jejunum during elective robotic assisted laparoscopic sleeve gastrectomy (Case #397)

• Medical Probability: 9 / 10
• Medical Error Summary: When using a visiport, it is imperative that you proceed cautiously, having a high index of suspicion. It became apparent that there was in injury, and the case was correctly converting to an open ca...
• Causation Probability: 9 / 10
• Causation Summary: As described above, placing the initial port in the midline has an increased injury risk. Additionally, one should be able to see the layers of the abdominal wall with the visiport given the contrast...
• Expert Summary: I am a robotic surgeon and work as a trauma and acute care surgeon I have 18 years of experience post fellowship and work at a busy level one verified trauma center
• Similar Summary: I manage trocar injuries as part of my practice. They are quite rare, but are managed similarly to other penetrating injuries.

52yo female right thyroid lobectomy and isthmusectomy, has significant burn injury to neck. (Case #399)

• Medical Probability: 8 / 10
• Medical Error Summary: There is obviously a burn superior to the incision site. most likely from a bovie. This can be seen during this type of surgery but not a full thickness burn that this appears to be. It was not desc...
• Causation Probability: 7 / 10
• Causation Summary: To give that deep of a burn during neck surgery, the surgeon would have been using poor and careless technique. It is incumbent on the surgeon to see the whole field that an energy releasing instrume...
• Expert Summary: I am a trauma and acute care surgeon at a busy verified level one trauma center ad have worked i this setting for 18 years. I do may tracheostomies with similar incisions to thyroid surgery incisions...
• Similar Summary: I have seen bovie injuries occasionally,, but never a full thickness injury that this appears to be

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

• Medical Probability: 9 / 10
• Medical Error Summary: When there is free fluid in the abdomen after trauma with the absence of solid organ injury, there should be a high suspicion of hollow viscus injury. This is especially true in males. (Women can hav...
• Causation Probability: 8 / 10
• Causation Summary: If the injury would have been noted at the first admission, it may have been that the patient could have avoided bowel resection, or, more likely, could have avoided a colostomy. I With prompt diagno...
• Expert Summary: I have been a full-time trauma and acute care surgeon at a busy level one academic trauma center for 16 years.
• Similar Summary: I see blunt trauma patients virtually every day I am on the trauma service which is about 7-9 days a month

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: 7 / 10
• Medical Error Summary: The documentation is difficult to interpret. It reports that the endotracheal tube was inserted at 1723 but then the documentation of intubation drugs and cricoid pressure was at 1731. The documenta...
• Causation Probability: 6 / 10
• Causation Summary: It appears that there was no steroid treatment for an allergy to Ancef. Also, given the temporal relationship to the Veres needle and the hemodynamic collapse, it is possible that the needle contribu...
• Expert Summary: I am professor of surgery at a busy verified level one trauma center, where I have worked for over 16 years. I serve as the medical director of the scute care surgery section for the hospital. I am ...
• Similar Summary: I do a lot of laparoscopic and robotic surgery using various methods of peritoneal access (Veres needle, optiview, Hasan port), and I am familiar with the complications and management of those complic...

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

• Medical Probability: 10 / 10
• Medical Error Summary: Concern for compartment syndrome is a medical emergency and must be addressed in the most urgent of manners. Any delay could cause premanant damage or amputation
• Causation Probability: 10 / 10
• Causation Summary: No one disagreed that this was compartment syndrome but there was not prompt action to get the patient the care he needed. There is 2 ways this case should have been handled. 1. Ideally, the ortho...
• Expert Summary: I am professor of surgery at a busy verified level one trauma center with 20 years of experience. I manage compartment syndrome of the lower and upper leg as well as the gluteal area, and assist in m...
• Similar Summary: This is a rare injury, but I manage compartment syndrome many times per year.

Recurrent Hernia (Case #547)

• Medical Probability: 6 / 10
• Medical Error Summary: CT scans are very effective at diagnosing epigastric hernias, but not perfect. It seems in this case the CT scan showed that there was not a hernia, but one was found at the time of exploration. An ...
• Causation Probability: 6 / 10
• Causation Summary: This is a challenging case due to the small but non-zero false negative rate of CT scan. If the patient does not have symptoms in the preop setting, these hernias can be difficult to find in the OR. ...
• Expert Summary: I am professor of surgery at a large academic medical center with 20 years' experience in hernia surgery. I do open, laparoscopic ad robotic approached to hernia repair.
• Similar Summary: I do several robotic epigastric/ventral hernias per month in my practice, and I have seen small hernias that are missed by imaging, and physical exam that require further surgery