60yo Male has "plasma rhizotomy" for chronic hip pain, has immediate evidence of nerve injury (Case #388)

• Medical Probability: 8 / 10
• Medical Error Summary: I can go in details when I review the case, however in short, it seems that upon looking at a NCS thereafter there was damage to the sciatic nerve. This nerve is usually not affected otherwise. It see...
• Causation Probability: 7 / 10
• Causation Summary: Yes, given this is not a 'usual' procedure that is done as an interventional pain management physician, I believe there is some merit here.
• Expert Summary: I am double board certified in anesthesiology and interventional pain management. I am the program director for the pain fellowship program at my institution. I am very clinical and perform over 150 p...
• Similar Summary: Upon occasion, however not this specific case.

56yo has rotor cuff repair, initial supraclavicular block and second rescue block. Develops pneumothorax. (Case #414)

• Medical Probability: 5 / 10
• Medical Error Summary: Given the background of the case, I believe that the rescue block was warranted status post the surgery. With the rescue block that was placed, there does carry a risk of a pneumothorax from the proce...
• Causation Probability: 5 / 10
• Causation Summary: Although it cannot certainly be proven as a causation, this type of lock can carry as very small risk/sequela of a pneumothorax. This should have been spoken about in the informed consent.
• Expert Summary: I am a double board-certified, anesthesiologist and interventional pain management position. I am the program Director for the pain management fellowship program in my institution. Although I wear man...
• Similar Summary: Almost every day. Although we don’t necessarily see pneumothorax, we do participate in these blocks very frequently.

Failure to secure IV, monitor, and assess patient in prone position on OR table. (Case #432)

• Medical Probability: 9 / 10
• Medical Error Summary: Positional errors do happen under anesthesia however they are often found after the patients is woken up post operatively. In this case, there was a combination of what seems like an infiltrated IV (t...
• Causation Probability: 9 / 10
• Causation Summary: The patient was awake and was prone for a colorectal surgery. The fact she has an injury to the deltoid says it all. It’s not secondary to anything else but the position during the surgery. We can d...
• Expert Summary: I am a double board certified anesthesiologist and pain management physician. I review these type of cases quite often for our internal PI/QI committees.
• Similar Summary: At least once a month we encounter a position error.

66 year old women with significant comorbidities including prior heart infarct and lung process, dies during non-emergent exploratory laparoscopy for bowel obstruction. (Case #445)

• Medical Probability: 6 / 10
• Medical Error Summary: In short, there should have been proper, cardiac and pulmonary consultation prior to the patient undergoing general anesthesia. this case demonstrates a patient with already compromised, lungs and hea...
• Causation Probability: 6 / 10
• Causation Summary: I think that the insufflation caused an already compromised patient to have bradycardia and subsequently needing compressions. There is a causation, whereas the insufflation likely caused the sequence...
• Expert Summary: I am a double board-certified, anesthesiologist and pain management position. I work at a large academic center and I am the program Director for the pain management Fellowship. I have been practicing...
• Similar Summary: Often enough as we see insufflation injuries, as well as very sick patients in our hospitals.

Steroid injections into severely degenerative hip with known effusion and synovitis (Case #554)

• Medical Probability: 2 / 10
• Medical Error Summary: It seems that the Pain physician who did the hip injection was doing it for the benefit of the patient. The patient seemed to get better from that initial injection and or requested another injection ...
• Causation Probability: 3 / 10
• Causation Summary: This patient may have already had an underlying issue with being more susceptible to infections. I don’t think that the steroid injection that the physician did illicit in a septic response, especia...
• Expert Summary: I am a double board certified anesthesiologist and pain management physician. I am the program Director for the pain management fellowship program at my institution. I see a large variety of different...
• Similar Summary: Often. Not necessarily with the infection, but with hip osteoarthritis.