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

• Medical Probability: 6 / 10
• Medical Error Summary: There has likely been a medical error here. Despite obtaining the critical view of safety , the surgeon describes a large size of the duct that had to be taken with a stapler and the moment that saw ...
• Causation Probability: 6 / 10
• Causation Summary: Given the location of the injury, Common bile duct and common hepatic duct, the surgeon must have been lower than they should have been, thus resulting in the injury.
• Expert Summary: I have performed over 1000 Laparoscopic cholecystectomies
• Similar Summary: Within my group of nine surgeons we see this at least 1/year

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

• Medical Probability: 6 / 10
• Medical Error Summary: The wound should not have been closed by the ED physicians after the stab wound and he should have been on antibiotics
• Causation Probability: 8 / 10
• Causation Summary: Closure of the wound led to infections and necrotizing fasciitis
• Expert Summary: I perform over 100 cases on Necrotizing fasciitis per year
• Similar Summary: We have a busy acute care surgery practice within an academic medical center. I see necrotizing fasciitis regularly as stated above

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

• Medical Probability: 7 / 10
• Medical Error Summary: This patient should have had a bronchoscopy at the time she started coughing out blood, particularly given her prior history of tracheo-innominate fistula
• Causation Probability: 7 / 10
• Causation Summary: There appears to be a delay in diagnosis, and not moving the patient to a higher level of care
• Expert Summary: You need someone who treat trauma patient and this was a multiply injured patient who suffered a significant life-threatening complication that may or may not have contributed to her death
• Similar Summary: This is rare. Though the trauma mechanism and the resultant injury is not uncommon, the complications and the manner of death is unusual

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

• Medical Probability: 6 / 10
• Medical Error Summary: Patients should have had the EGD sooner, since the gastric bypass surgery was over 3 months. Unclear based on the available history what happened when he was in the step down unit
• Causation Probability: 6 / 10
• Causation Summary: Patient neurological deterioration " minimally responsive" was not followed up on
• Expert Summary: Acute care general surgeon in an academic surgical practice with 17 years experience
• Similar Summary: Approximately four to five time a year

Patient Death following Cholecystectomy (Case #355)

• Medical Probability: 7 / 10
• Medical Error Summary: patients had worsened Coagulopathy without knowing why even after the delay on June 6th. A liver function test result is necessary to know what her liver function was before surgery. Given the descri...
• Causation Probability: 6 / 10
• Causation Summary: Anemic patient with Sickle cell disease who is coagulopathic before surgery should not have had surgery without correction of coagulopathy or she should have had a cholecystostomy tube placed.
• Expert Summary: Over 18 years experience as an acute care surgeon, and I have done over 600 laparoscopic cholecystectomies
• Similar Summary: two patients /year with sickle cell disease

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: 6 / 10
• Medical Error Summary: Euroseal devices are not adequate in draining a pneumothorax in the presence of significant chest wall injury and hemothorax. This patient should have been transferred to a higher level of care
• Causation Probability: 6 / 10
• Causation Summary: There seem to be a delayed diagnosis regarding the real cause of the pneumothorax and penumomediatimun, it could be a large airway injury or even an esophageal injury. Based on the information provid...
• Expert Summary: I am a board certified trauma critical care surgeon with 17 years experience
• Similar Summary: massive pneumothorax is seen about 10-15 times a year in my practice

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

• Medical Probability: 7 / 10
• Medical Error Summary: Given the patients scoliosis and Cervical spine trauma , an open tracheostomy should have been performed
• Causation Probability: 7 / 10
• Causation Summary: As stated above and the procedure should have been abandoned when difficulty was encountered and there was no indication that a bronchoscope was used.
• Expert Summary: I perform over 50 bedside and open tracheostomies per year
• Similar Summary: Once a year, this is relatively rare but a known complication. the sequelae in this case is devastating

During a routine hernia repair, surgeon mistakes PC's urethral sphincter prosthetic fluid reservoir for an abdominal seroma and does needle aspiration., damages prosthetic. (Case #374)

• Medical Probability: 6 / 10
• Medical Error Summary: the general surgeon was not used to seeing prosthetic penile implants with reservoir and should have had urology come see the patient intra-operatively
• Causation Probability: 6 / 10
• Causation Summary: Lack of understanding of abdominal anatomy and characteristics of penile implants
• Expert Summary: I am an acute care surgeon, I perform lots of abdominal wall hernia repairs acutely
• Similar Summary: Once per year, this is not very common

Hernia repair w/ fundoplication, later found to have esophageal perforation and also a surgical stitch in pericardium. (Case #380)

• Medical Probability: 10 / 10
• Medical Error Summary: Having an esophageal perforation is a known complication but have a stitch in the pericardium is unusual
• Causation Probability: 9 / 10
• Causation Summary: Given the deterioration after the initial operation, the gastric necrosis and the damage to the pericardium, this was caused by the hiatal hernia repair without which it would not have happened
• Expert Summary: I am an acute care surgeon/Trauma with experience in gastric resection
• Similar Summary: Rarely, have a pericardial injury from a funduplication is rare

Sigmoid diverticulitis with contained perforation and abscess. Hartmann’s procedure done and develops fistula and large wound, multiple complications. (Case #381)

• Medical Probability: 5 / 10
• Medical Error Summary: This is a known complication of sigmoid colectomy particularly given that she had a contained perforation prior to her first surgery.
• Causation Probability: 5 / 10
• Causation Summary: the reason for the fistula are multiple, it could be a complication of her her perforation with a pre-existing fistula that declared itself after surgery, or it could have occurred at the time of t...
• Expert Summary: As an acute care surgeon , I perform this operation about 20/year. these are challenging cases
• Similar Summary: 2-3/year, Though this is rare, this complication is well known

78yo M with SBO with distention/poss GI bleed, confused and pulls NG tube out. It is electively not replaced by surgeon and PC later arrests. (Case #390)

• Medical Probability: 7 / 10
• Medical Error Summary: This patients aspirated from a full stomach. the NG tube should have been replaced
• Causation Probability: 8 / 10
• Causation Summary: With vomitus around the patients mouth, most likely cause of death is aspiration
• Expert Summary: I am an Acute care surgeon with 18 years experience
• Similar Summary: I treat SBO all the time, at least 2 patients a week