Newsletter
Malpractice Case Studies Aren’t Just Somebody Else’s Troubles
Jan 31, 2022
While malpractice cases are rare for individual physicians (fewer than 4 of 100 per year), mistakes in the delivery of care are ubiquitous.
Fortunately, the vast majority of those mistakes do not lead to significant permanent harm and, in a continuous learning environment, those missteps are captured as event data. Unquestionably, aggregated patient safety data are essential to raise awareness and focus finite resources, but without a narrative context, many of us can become dazed rather than dazzled by the charts and graphs.
For sustained learning, nothing takes the “numb” out of numbers like a poignant story. The cases listed below include a chronology of the clinical events and specific recommendations for patient safety improvement that align with key areas of vulnerability across a range of specialties and clinical disciplines.
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Unclear Discharge Instructions, Patient Loses Foot [podcast] “I injured my foot after a box fell on it. They dressed it up in the ER, and I went home. After a few days it’s hurtin’ bad. I go back to the ER and then they said they have to cut off part of my foot.” |
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Case Type Medical treatment |
Responsible Service Emergency Medicine |
Outcome Closed without payment |
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Unacknowledged PSA Test Result Delays Prostate Cancer Diagnosis Two years after an elevated PSA test result went unaddressed, the patient was diagnosed with prostate cancer. |
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Case Type Diagnosis |
Responsible Service General Medicine |
Outcome Closed with high-range payment ($500,000–$999,999) |
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A Failure to Document Patients Refusal A 60-year-old man’s allegation of a failure to diagnose colon cancer was complicated by his undocumented refusals of recommended cancer screenings. |
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Case Type Diagnosis |
Responsible Service General Medicine |
Outcome Closed with high-range payment ($500,000–$999,999) |
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Woman Dies from Post-op Stroke When Anticoagulant Not Restarted [podcast] “My mother underwent a procedure in the cath lab. But they didn’t put her back on blood thinners after the operation and she had a stroke. |
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Case Type Medication |
Responsible Service General Medicine |
Outcome Closed with payment >$2.5M |
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Surgical Change Needed Consent [podcast] A 25-year-old woman presented with history of an acoustic neuroma resection on the right side and neurofibromatosis type II (a genetic tumor suppressor syndrome). |
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Case Type Surgery/ |
Responsible Service Neurosurgery |
Outcome Closed with payment >$1M |
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Woman’s Stroke Progressed in ED without Intervention [podcast] An 83-year-old woman with a history of multiple stroke risk factors was brought to the Emergency Department by her daughter who noticed her mother “sounded strange” during a phone conversation. |
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Case Type Patient Monitoring |
Responsible Service Nursing |
Outcome Closed with mid-range payment ($100,000–$499,999) |
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EHR Error exacerbates adverse event during transport Failure to monitor a patient's physiological status during intra-hospital transport. |
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Case Type Intra-hospital Transfer |
Responsible Service Nursing |
Outcome Closed with high-range payment ($500,000–$999,999) |
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Lack of Preparation, Safety Culture, Contributed to Loss of Baby [podcast] Early in this case, the team faced some adverse circumstances that left them unprepared for the complications they were up against. |
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Case Type Obstetrics-related |
Responsible Service Obstetrics |
Outcome Closed with payment >$1M |
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Severe Consequences of Copy and Paste Documentation A physiatrist repeatedly entered identical notes in the medical record, while nurses, physical therapists, and occupational therapists all documented subtle declines in the patient’s condition. |
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Case Type Medical Treatment |
Responsible Service Physiatry |
Outcome Closed with payment >$1M |
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Misread and Missed Opportunities A 55-year-old man’s lung cancer diagnosis was delayed by five years after an initial X-ray was misread and no follow-up study was performed. |
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Case Type Diagnosis |
Responsible Service Radiology |
Outcome Closed with payment >$2M |
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View more case studies or listen to some in podcast format. |
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