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

• Medical Probability: 4 / 10
• Medical Error Summary: The CTA neck obtained after the neurologic symptoms demonstrated a Left vertebral artery dissection. Had the patient undergone a CTA neck at initial workup, this may have been identified and she may h...
• Causation Probability: 4 / 10
• Causation Summary: As above, it seems the outcome follows from the Left vertebral dissection, but the failure to diagnose the dissection at admission is not an error UNLESS there were clear indications to order a CTA ne...
• Expert Summary: I am a trauma surgeon who practices surgical critical care as well. I have treated numerous patients with blunt cerebrovascular injury like this one. These are challenging injuries - young patients wi...
• Similar Summary: Patients with blunt cerebrovascular injury: 1-2 monthly Patients with devastating sequelae of BCVI: 1-2 yearly

Colon perforation while inpatient (Case #316)

• Medical Probability: 7 / 10
• Medical Error Summary: Diverticulitis is a common problem and while most cases can be managed with antibiotic therapy, patients are certainly at risk of disease progression with complications such as bowel perforation. My c...
• Causation Probability: 6 / 10
• Causation Summary: It is impossible to know when the perforation occurred, however it is likely that an earlier operation may have prevented such significant intra-abdominal contamination and the subsequent profound inf...
• Expert Summary: I am an acute care surgeon who practices trauma surgery, emergency general surgery and surgical critical care. I have taken care of similar such patients, particularly in the ICU on a near weekly basi...
• Similar Summary: I take care of patients with complicated diverticulitis on a near weekly basis. I have managed people with a similar course in the ICU nearly every time I round in the unit (every month)

Death after tracheostomy (Case #320)

• Medical Probability: 5 / 10
• Medical Error Summary: The increased work of breathing on post day #2 with increased volume and bloody secretions are concerning. There was already enough bleeding from the tracheostomy that the patient required a second op...
• Causation Probability: 7 / 10
• Causation Summary: The failure to intervene earlier to identify and stop the bleeding may have prevented the airway obstruction with clot that led to the cardiac arrest and hypoxemia with anoxic brain injury.
• Expert Summary: I am a surgeon practicing trauma surgery and surgical critical care. I perform tracheostomies frequently in the ICU and operating room. I take care of patients with tracheostomies, including complicat...
• Similar Summary: I probably see complications of tracheostomy 2-4 times annually. I have performed repeat tracheostomy multiple times and am very cognizant of the risks of bleeding and tracheal necrosis

No Surgery for Abdominal Bleed (Case #321)

• Medical Probability: 7 / 10
• Medical Error Summary: A rectus sheath hematoma with active bleeding in an unstable patient requires some kind of intervention. Surgey, however, is not the best intervention - interventional radiology for embolization of th...
• Causation Probability: 8 / 10
• Causation Summary: The patient required more aggressive intervention than she received. She clearly decompensated more quickly than expected, but an evaluation by IR and embolization MAY have stopped the bleeding before...
• Expert Summary: I am a surgeon practicing trauma, acute care surgery and surgical critical care. I treat patients with with hemorrhagic shock on a near daily basis. I treat patients with rectus sheath hematomas on a ...
• Similar Summary: Please see my above answer. At least once a month I treat rectus sheath hematomas

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

• Medical Probability: 10 / 10
• Medical Error Summary: Complications in laparoscopic cholecystectomy are often related to the fact that the surgeon's perception of the anatomy was incorrect. It is often difficult to reconstruct what the surgeon thought th...
• Causation Probability: 10 / 10
• Causation Summary: If there is confusion about the anatomy, a surgeon has several options to try to stay out of trouble. As stated above, it is helpful to have a colleague come into the room to ask their opinion. Th...
• Expert Summary: I am an acute care surgeon practicing trauma, emergency general surgery and surgical critical care. I perform cholecystectomies ~ 10 times/month. Most of these are not elective procedures but rather u...
• Similar Summary: As stated above, I probably perform ~10 cholecystectomies per month. In our center, however, we probably treat a patient with an injury every other month. I work in a teaching hospital and we discuss ...

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

• Medical Probability: 8 / 10
• Medical Error Summary: For which decision? - Regarding the emergency medicine providers who saw the patient after the initial stab wound who irrigated, sutured it, and discharged the patient: it depends on whether the wo...
• Causation Probability: 8 / 10
• Causation Summary: Focusing on the delay in bringing the patient back to the OR: yes, this delay very likely (8) resulted in the patient's worsening multiple organ failure (septic shock, kidney failure, hyperkalemia) th...
• Expert Summary: I am an acute care surgeon practicing trauma surgery, emergency general surgery and surgical critical care. I am often called on to evaluate patients for necrotizing soft tissue infection. I have oper...
• Similar Summary: Necrotizing soft tissue infections are not common, and overwhelming ones that move with such speed are rare. I probably see NSTIs a few times a month, but ones as severe as in this case probably 2-3 t...

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

• Medical Probability: 3 / 10
• Medical Error Summary: The patient sustained multiple injuries and arrived at the trauma bay intubated and in hemorrhagic shock. Based on the brief summary, the patient received massive blood product transfusion. Without re...
• Causation Probability: 3 / 10
• Causation Summary: It is unclear to me that either blood transfusion or iodinated contrast resulted in distributive shock that lasted 4 days. I would be concerned about other etiologies, such as a missed intra-abdominal...
• Expert Summary: I am an acute care surgeon at an academic Level I trauma center, and I treat patients with poly trauma and mixed shock on a regular basis both in the trauma bay, the operating room, and the surgical I...
• Similar Summary: I deal with poly trauma patients and patients in shock on a daily basis.

Death from diffuse alveolar hemorrhage over two months after motorcycle crash (Case #350)

• Medical Probability: 6 / 10
• Medical Error Summary: More likely than not with a large caveat: Based on the autopsy results, the patient died due to bleeding from diffuse alveolar hemorrhage (DAH), and it appears the treatment team missed the diagno...
• Causation Probability: 6 / 10
• Causation Summary: The missed diagnosis meant that the treatment team couldn't render appropriate care. This may be classified as a failure to rescue from the complication. It is unclear from the summary, but becaus...
• Expert Summary: I am an acute care surgeon practicing trauma surgery and emergency general surgery, and I am the medical director of the trauma/surgery intensive care unit at a Level 1 trauma center. I manage patient...
• Similar Summary: I have seen diffuse alveolar hemorrhage related to trauma roughly once every year or two. The last case we managed with inhaled TXA to good effect.

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

• Medical Probability: 6 / 10
• Medical Error Summary: The patient developed a marginal ulcer with bleeding and eventual perforation at the gastrojejunostomy four months after his initial roux-y gastric bypass. At his presentation on 4/11, neither GI nor ...
• Causation Probability: 7 / 10
• Causation Summary: Please see above -- delay in diagnosis, delay in getting patient to surgery, prolongation of hemorrhagic shock leading to depleted physiologic reserve.
• Expert Summary: I am an acute care surgeon and the medical director of our trauma/surgical ICU at a Level 1 trauma center. I perform a great deal of emergency general surgery, including on post-bariatric surgery pati...
• Similar Summary: Several times per year, both as primary surgeon, as critical care attending, or as a consultant for my bariatric colleagues

Abdominal bleed/anastomotic leak (Case #357)

• Medical Probability: 8 / 10
• Medical Error Summary: The patient presented to the emergency department one week after robotic colostomy takedown with bright red blood per rectum; in shock (tachycardia and hypotension); and with acute kidney injury (crea...
• Causation Probability: 8 / 10
• Causation Summary: The question is whether an earlier ex lap may have resulted in fewer intra-abdominal abscesses and the series of multiple operations, open abdomen and associated complications. I can imagine that the ...
• Expert Summary: I am a surgeon practicing acute care surgery, trauma surgery, and surgical critical care. I am the medical director of the Surgical ICU at an academic, Level 1 trauma center. I perform damage control ...
• Similar Summary: I manage patients similar to this one probably once per month

Possible failure to transfer to trauma center for trauma involving chest injuries with resultant death due to pulmonary decompensation and arrest. (Case #358)

• Medical Probability: 8 / 10
• Medical Error Summary: The initial management of blunt chest trauma with a closed suction drain is appropriate. However, the challenge comes when that initial management is insufficient or the patient's course begins to dev...
• Causation Probability: 7 / 10
• Causation Summary: If the patient had been at a trauma center, he may have undergone further evaluation of his pneumomediastinum, had a thoracic surgeon involved, or undergone surgery to evaluate his worsening pulmonary...
• Expert Summary: I am a surgeon practicing trauma surgery, acute care surgery and surgical critical care. I am the medical director of the Trauma/Surgical ICU at an academic Level 1 trauma center. I manage patients wi...
• Similar Summary: I encounter severe blunt chest trauma every trauma shift. I manage patients with decompensating respiratory function related to their chest injuries at least weekly.