Delayed diagnosis of appendicitis? (Case #294)

• Medical Probability: 5 / 10
• Medical Error Summary: Right-middle abdominal tenderness, elevated WBC and the CT findings should ideally have triggered a surgical consult. However, it is likely that the surgical service would also have recommended discha...
• Causation Probability: 4 / 10
• Causation Summary: Had the patient followed the (admittedly poor) return instructions, he likely wouldn't have experienced this complicated and life-threatening course. It is unlikely that even with a surgical consultat...
• Expert Summary: I see patients similar to this patient on his first visit quiet frequently. I can speak to the role of surgical consultation and the importance of a thorough discussion of the follow-up care/return pr...
• Similar Summary: I would estimate that I see a case similar to this patient on his first visit about once or twice per month.

Foot infection after foreign body leads to gangrene, toe amputations (Case #311)

• Medical Probability: 9 / 10
• Medical Error Summary: 6/15 visit met criteria for further investigations, suspect the patient was already infected at this visit. Her tachycardia and physical exam findings of the foot are concerning.
• Causation Probability: 8 / 10
• Causation Summary: Earlier intervention on 6/15 (expanded labs, CT, IV antibiotics, admission) would have likely mitigated the disease progression or at least would have led to earlier intervention. The physician evalua...
• Expert Summary: One of less than physicians in the national triple board-certified in emergency medicine, critical care medicine and EMS (prehospital medicine). I work at the second-highest acuity ED in the nation an...
• Similar Summary: Once a quarter in ED, 10 times a year in the ICU/inpatient setting

Stab wound, necrotizing fasciitis, death (Case #326)

• Medical Probability: 8 / 10
• Medical Error Summary: As an intensivist, I am concerned about the delay in surgical treatment on 12/128/21. An initial plan for operative intervention was made, but doesn't occur until the following morning. At this point,...
• Causation Probability: 7 / 10
• Causation Summary: It is well known that timely surgical intervention (and re-intervention) is critical to prevent the often very rapid decline seen with necrotizing soft tissue infections. The surgical team documented ...
• Expert Summary: I am one of only a handful of physicians in the United States who is board-certified in Emergency Medicine, Critical Care Medicine, and EMS. I practice in all three specialties, and my clinical ICU pr...
• Similar Summary: Once every 3-4 months. I see less complicated (non-fatal) cases of necrotizing soft tissue infections on a monthly basis.

Death After MVC (Case #329)

• Medical Probability: 6 / 10
• Medical Error Summary: The exact events and timeline are somewhat difficult to reconstruct. However, it appears that the patient very quickly declined from a near-normal mental status to cardiac arrest (however, even with a...
• Causation Probability: 7 / 10
• Causation Summary: 1) Failure to timely address persistent hypoxemia prior to potentially preventable respiratory arrest 2) Failure to upgrade to a level 1 trauma alert which would typically lead to a larger response, ...
• Expert Summary: I am one of less than ten physicians in the US who is triple board certified in emergency medicine, critical care medicine, and emergency medical services (prehospital medicine).I practice in all thre...
• Similar Summary: I see patients as the ED physician in charge of the airway 2-4 times per shifts. I also take care of trauma patients in the ICU and when working prehospitally as an EMS physician. I teach residents an...

ER Treatment of Rocephin-Induced Anaphylaxis (Case #379)

• Medical Probability: 7 / 10
• Medical Error Summary: Based on the information provided so far, there was a delay in recognition of the patient's severity. While anaphylaxis can always occur, the response provided was limited as evidenced by the delay in...
• Causation Probability: 8 / 10
• Causation Summary: Delay in recognition of anaphylaxis Delay in airway management Possible shortcomings in peri-intubation physiologic management leading to cardiac arrest
• Expert Summary: I am one of only a handful physicians in the US triple-boarded in prehospital emergency medicine, emergency medicine, and critical care medicine. I practice all three specialties, and work in a large ...
• Similar Summary: I estimate that I see cases of severe anaphylaxis every 4-6 weeks. I perform critical airway management over a hundred times per year.

ED visit with abdominal pain, elevated WBC, discharged yet returns later same day with perforated appendix (Case #431)

• Medical Probability: 8 / 10
• Medical Error Summary: Classic case of missed appendicitis due to overreliance on imaging despite highly suspicious constellation of symptoms and leukocytosis. No offer of admission for serial abdominal exams, no surgical c...
• Causation Probability: 6 / 10
• Causation Summary: There is a greater than 50% likelihood that with a surgical consultation during the first visit or prolonged observation/admission for serial exams, a definitive intervention would have occurred soone...
• Expert Summary: I am one of only a few physicians in the nation who is triple board-certified in Emergency Medicine, Emergency Medical Services (EMS, prehospital medicine), and Critical Care Medicine. I am a Fellow o...
• Similar Summary: A young patient with abdominal pain and leukocytosis, but “negative” or inconclusive imaging is a fairly common presentation that I see several times a year (and appendicitis per se is a very comm...

Stroke Symptoms ignored leading to death (Case #486)

• Medical Probability: 6 / 10
• Medical Error Summary: Although severely elevated blood pressure does not automatically constitute a hypertensive emergency in the absence of documented end-organ damage, the patient’s overall clinical presentation at the...
• Causation Probability: 6 / 10
• Causation Summary: A more comprehensive evaluation or admission at the initial visit could have identified concerning neurological findings or would have allowed for close monitoring, which in turn may have led to a sig...
• Expert Summary: am one of only a small number of physicians nationwide who is triple board-certified in Emergency Medicine, Emergency Medical Services (prehospital medicine), and Critical Care Medicine. I am a Fellow...
• Similar Summary: I practice in a large quaternary-care emergency department where I routinely evaluate patients across the full spectrum of hypertensive presentations, including asymptomatic hypertension, hypertensive...

54yo M Intoxicated MVC Patient Released Without Head CT; Later Fatal Subdural Hemorrhage (Case #556)

• Medical Probability: 6 / 10
• Medical Error Summary: My main concern is the fact that no imaging was done in a severely intoxicated patient and there is no reported documentation so far outlining a rationale for foregoing imaging (was the patient a chro...
• Causation Probability: 6 / 10
• Causation Summary: Intracranial hemorrhage is a potentially life-threatening injury. It is likely this patient would have been admitted for further care, and the outcome could have been avoided.
• Expert Summary: I have received emergency medicine for over 15 years. I am one of only a handful of physicians in the country triple-boarded in emergency medicine, critical care medicine, and EMS. I serve as Vice-Cha...
• Similar Summary: I see patients with a combination of the factors that are notable in this case almost every shift. Specifically, head injury after MVC In an intoxicated patient inquire common as well.

Delay in diagnosing dissecting aortic aneurysm? (Case #574)

• Medical Probability: 3 / 10
• Medical Error Summary: Not enough detail is provided as to what exactly occurred intraoperatively and what the patient’s condition was prior to transfer. Generally speaking, this patient was transferred fairly expeditious...
• Causation Probability: 3 / 10
• Causation Summary: Even if a claim of delay in transfer was sustained, with the level of information currently available, it would be difficult to clearly tie the time to transfer to the patient’s death.
• Expert Summary: I am a senior administrative leader at a quarternary academic center who has deep experience and expertise in clinical emergency care and operations. As an EMS-boarded physician, I have in-depth knowl...
• Similar Summary: I frequently diagnose and treat patients with type A aortic dissections, and also receive these patients in transfer.

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

• Medical Probability: 4 / 10
• Medical Error Summary: Standard of care would have required formal neurosurgery consultation for a patient with concern for discitis/osteomyelitis. However, the treatment course would’ve likely been the same, meaning that...
• Causation Probability: 4 / 10
• Causation Summary: It is unlikely that neurosurgical consultation would have changed the course. Whether repeat imaging would have impacted the ultimate outcome is also quite uncertain. The same holds true for a relativ...
• Expert Summary: What makes you a good expert for this case? I am a senior administrative physician leader at a quarternary academic center who has deep experience and expertise in clinical emergency care and opera...
• Similar Summary: I see patients presenting who present with concern for discitis/OM and similar clinical question/needs several times a month.