Death after tracheostomy (Case #320)

• Medical Probability: 7 / 10
• Medical Error Summary: Based on the above information available, I believe there were multiple opportunities for improvement in this case regarding the management of the tracheostomy and chain of events that ultimately put ...
• Causation Probability: 8 / 10
• Causation Summary: The patient had frequent lavages which required instrumentation of the tracheostomy and trachea which is a risk factor for repeated injuries to the tracheal wall. I would need clarification of what...
• Expert Summary: As an acute care surgeon, I often perform tracheostomies as part of my routine practice. I also have managed complications of these cases, including a tracheo innominate fistula, during my practice. ...
• Similar Summary: While my suspected diagnosis of a tracheo innominate fistula is a very rare complication overall, I have seen it 5 times in my career. However, similar cases where there is bleeding in or around tr...

No Surgery for Abdominal Bleed (Case #321)

• Medical Probability: 8 / 10
• Medical Error Summary: Based on the information available to me, there was a significant delay in diagnosis and recognition in hemorrhagic shock. The patient initially had documented signs on exam based on the 07/16 1621...
• Causation Probability: 10 / 10
• Causation Summary: As above, there is a significant delay in diagnosis of hemorrhagic shock, significant delay in time to resuscitation with blood products, lack of involvement of key consultants such as IR who was not ...
• Expert Summary: I am a trauma surgeon with vast experience in recognition and management of hemorrhagic shock. This includes when surgical management is warranted as well as when surgery is not warranted but non-ope...
• Similar Summary: Hemorrhagic shock management is nearly a daily consultation to my service in my practice.

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

• Medical Probability: 10 / 10
• Medical Error Summary: Even though the surgeon describes triangle of safety within operative report, there was clearly an injury to the hepatic duct and artery at the index operation. I would need to see a detailed review o...
• Causation Probability: 10 / 10
• Causation Summary: This injury could only have been caused by intraoperative decision making and incorrect identification of anatomical structures related to cholecystectomy.
• Expert Summary: Cholecystectomy is part of my routine daily practice and I have managed hundreds of patients during my career including dealing with complications as you’ve outlined above.
• Similar Summary: This is an extremely rare complication as correct identification of the critical view of safety is paramount before proceeding with surgical division of the cystic duct and artery, however, I have see...

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

• Medical Probability: 10 / 10
• Medical Error Summary: There was a significant delay between the time surgery was consulted with findings of necrotizing soft tissue infection and time to OR. This is a surgical emergency and ideally needs to be done within...
• Causation Probability: 9 / 10
• Causation Summary: While the patient presented with the infection, it’s the surgeon’s job to achieve source control ideally at the index operation. As long as there is ongoing need for debridement, daily return to t...
• Expert Summary: As an acute care surgeon, I’ve managed nearly 1,000 penetrating injuries during my career. Necrotizing soft tissue infection is something I’ve encountered many times throughout my career, both sur...
• Similar Summary: As I stated above, this is something I see often in my career. Our service is consulted on this at least once a week.

Death After MVC (Case #329)

• Medical Probability: 10 / 10
• Medical Error Summary: Based on the available information above, there was significant opportunity for improvement in how this patient was managed. Pre-hospital, the patient had a significant mechanism - rollover MVC. I...
• Causation Probability: 5 / 10
• Causation Summary: Based on the above information, I do not think that a medical error resulted in an injury to the patient that was not already present on presentation from the MVC. However, the question becomes wheth...
• Expert Summary: I am a board certified acute care (trauma) surgeon that has managed over 2,000 patients in the trauma bay in my career. I have extensive experience in both blunt and penetrating trauma and am intrica...
• Similar Summary: I manage similar cases to this every day of my career and as above, I have managed over 2000 patients with significant blunt trauma.

Bilateral hernia mesh placement with complications (Case #337)

• Medical Probability: 3 / 10
• Medical Error Summary: There is a high association between lipoma of the cord and inguinal hernias, both at the time of findings and future risk. Therefore, there is a strong argument to treat lipoma of the cord when found...
• Causation Probability: 6 / 10
• Causation Summary: As above, if the symptomatology is related to the mesh (IE compression of the ileoinguinal nerve, local reaction from the mesh, entrapment from the suture technique during surgery), than there may hav...
• Expert Summary: I routinely manage inguinal hernias as part of my practice both in the elective and emergent setting. I am well versed in the techniques and complications associated with the surgery and would be com...
• Similar Summary: This is not a common complication-usually about 5-10% incidence. However, I have seen multiple mesh related complications throughout the course of my career.

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

• Medical Probability: 2 / 10
• Medical Error Summary: This is an extremely complex case from a trauma standpoint. However, focusing on the specific question posed - was this anaphylactic shock- it is highly unlikely that this is the etiology of the pa...
• Causation Probability: 3 / 10
• Causation Summary: This patient had a significantly high severe injury score based on the description above and thus a high risk of mortality from presentation. It is common for patients in this state to present initia...
• Expert Summary: I am a board certified trauma/critical care surgeon with extensive experience in a level 1 trauma center with over 2000 blunt and penetrating trauma cases treated during my time as an attending. I wo...
• Similar Summary: This is a common encounter in my practice, seeing several significant motor vehicle/motorcycle crashes multiple times in a week.

Surgical Resection- Mass in Colon (Case #348)

• Medical Probability: 2 / 10
• Medical Error Summary: In this case, appropriate pre-operative screening was done. The colonoscopy described is appropriate and helps guide future surgical intervention. Following the colonoscopy, the appropriate pre-ope...
• Causation Probability: 2 / 10
• Causation Summary: With a hand sewn anastomosis during the index operation, there was adequate opportunity to inspect the lumen and ensure no obstructions prior to completion. That said, it is likely that patient disea...
• Expert Summary: I have performed many colonic anastomoses in my career both in the elective and emergent setting from cancer or in the setting of inflammatory bowel disease. The approach for a transverse colon resec...
• Similar Summary: Although this is an overall rare complication (anastomotic breakdown), I have encountered many of these cases during my career and it is often a point of discussion at M&M regarding what could be done...

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

• Medical Probability: 8 / 10
• Medical Error Summary: It's difficult to ascertain from the information above if there was medical error. This is a multifactorial case with many events that may have posed as risk factors leading up to the terminal even...
• Causation Probability: 8 / 10
• Causation Summary: As above, a tracheoinnominate fistula is a preventable outcome and although it was recognized the first time and apparently addressed, the patient had what appeared to be another herald bleed on 07/05...
• Expert Summary: I have performed and managed hundreds of tracheostomies in my career as an acute care surgeon and am well versed in managing complications related to these procedures. Additionally, I have experi...
• Similar Summary: Management of tracheostomies including post-procedure bleeding is part of my routine practice. Management of TI fistulas is very rare in general, but I have managed several over the course of my care...

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

• Medical Probability: 10 / 10
• Medical Error Summary: There is high concern for both the initial management of this patient upon admission and for failure to rescue after the return to the operating room on 04./19. The patient underwent a Roux En Y gast...
• Causation Probability: 9 / 10
• Causation Summary: From the perspective of the patient developing a marginal ulcer following Roux En Y, this is a very common complication associated with the procedure and patients often present to the ER several weeks...
• Expert Summary: I am board certified in both general surgery and acute care surgery (including emergency general surgery and surgical critical care). I have routinely managed post-operative bariatric patients both f...
• Similar Summary: This is overall a rare complication, but I have encountered this type of case many times over the course of my career as an acute care surgeon.

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

• Medical Probability: 10 / 10
• Medical Error Summary: There was a significant delay in definitive care for this patient. When the patient was transferred from the initial ER to the trauma center (which was the correct management), the acute care surgery...
• Causation Probability: 10 / 10
• Causation Summary: Had the patient gone to the operating room on initial presentation to the trauma center, there is a possibility that the patient could have undergone a single definitive surgical intervention, had GI ...
• Expert Summary: I am board certified in general surgery as well as surgical critical care (emergency general surgery, trauma surgery). have managed hundreds of patients with motor vehicle collisions/blunt traumatic i...
• Similar Summary: Similar cases are part of my routine practice.

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: Based on the information available, there are multiple medical errors and more specifically, systems errors that occurred in this case. It is never acceptable to delay trauma and orthopedic evaluat...
• Causation Probability: 10 / 10
• Causation Summary: As above, if the trauma and orthopedic teams had evaluated the patient and expedited transfer quicker, there is a high probability that the patient may have avoided many if not all of complications du...
• Expert Summary: I am board certified in both general surgery and surgical critical care. I functioned as a full time active clinical acute care surgeon for several years in a level 1 academic center which included e...
• Similar Summary: While compartment syndrome cases are rare overall, I have reviewed several similar cases in the past. However, I have reviewed many similar cases where there was delayed care and resulting preventabl...