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It's Sarah, not Stephen!
with commentary by Urmimala Sarkar, MD, MPH
Although the mother of a child, born male who identified as and expressed externally as a girl, had alerted the clinic of the child's preferred name when making the appointment, the medical staff called for the patient in the waiting room using her legal (masculine) name.
A Picture Speaks 1000 Words
with commentary by Robin R. Hemphill, MD, MPH
Admitted to the hospital after hours, a patient with a history of type A aortic dissection had his CT scan read as "no acute changes." However, the CT scan had been compared to a text report of a previous scan, rather than the images. The patient died several hours later, and autopsy revealed the dissection had progressed and ruptured.
with commentary by Nicholas Symons, MBChB, MSc
An elderly woman with severe abdominal pain was admitted for an emergency laparotomy for presumed small bowel obstruction. Shortly after induction of anesthesia, her heart stopped. She was resuscitated and transferred to the intensive care unit, where she died the next morning. The review committee felt this case represented a diagnostic error, which led to unnecessary surgery and a preventable death.
From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case
with commentary by David E. Newman-Toker, MD, PhD
Admitted to the hospital with headache and word-finding difficulties, a man was given a preliminary diagnosis of vasculitis. Although serial imaging studies seemed to indicate progression of his brain lesions, these were not biopsied and discovered to be glioblastoma multiforme until 4 months later. The delay in diagnosis contributed to his rapid clinical decline.
with commentary by Reza Alaghehbandan, MD, MSc, and Stephen S. Raab, MD
A woman with abdominal pain, bloating, and weight loss went to her primary physician, who ordered imaging and a biopsy. Lymph node pathology was reported as Castleman disease. A specialist felt the presentation and test results were atypical for this diagnosis. Further testing revealed adult-onset celiac disease.
A Real Heartache
with commentary by Steven K. Polevoi, MD
Following an emergency department (ED) evaluation for chest pain, a patient was discharged with a presumptive diagnosis of gastroesophageal reflux disease. Two days later, he returned to the ED in severe distress, now with an acute myocardial infarction and a large pericardial effusion.
The Lung Nodule That Refused To Grow
with commentary by Alex A. Balekian, MD, MSHS, and Michael K. Gould, MD, MS
At his first visit with a new physician, a man with a "spot" on his lung reported being followed with CT scans every 6–12 months for 8 years. In total, the patient had more than 20 CT scans.
with commentary by Jeffrey M. Rohde, MD, and Scott A. Flanders, MD
A 32-year-old man went to the emergency department with fever and pleuritic chest pain. Following an extensive work-up, he was discharged with "fever, pleural effusion, and chest wall pain", but no clear diagnosis. He returned to the ED 3 days later with worsening pain, continued fever, a new cough, and dyspnea. The patient was started on antibiotics and admitted for pneumonia with effusion.
with commentary by Krishan Soni, MD, MBA, and Gurpreet Dhaliwal, MD
A man presented to the emergency department (ED) complaining of knee problems, and the triage nurse wrote down the chief complaint as "bilateral knee pain." The ED physician diagnosed a musculoskeletal injury and prepared to discharge him, but the patient was noticeably unsteady. Further examination and imaging revealed a subdural hematoma requiring urgent neurosurgical intervention.
Cultural Dimensions of Depression
with commentary by J. David Kinzie, MD
Admitted to the hospital complaining of difficulty breathing and swallowing, a Vietnamese man was diagnosed with reflux disease and an outpouching of the esophagus. The patient was anxious and repeatedly stated that he was "dying" from his physical ailments. During a gastroenterology consultation, the patient ran to the restroom and jumped out the window, killing himself.
Missing the Point—Eye Injury
with commentary by Rahul Sharma, MD, MBA; and Douglas Brunette, MD, MPH
A woman presented to the emergency department with an eyelid laceration, which was sutured without complication. Her visual acuity was not formally tested and ophthalmology was not consulted. Ten days later, she presented with eye pain and poor vision. Ophthalmologist evaluation revealed a ruptured globe requiring surgical repair.
Liver Failure After Chemotherapy: Did We Forget Something?
with commentary by John Lubel, MD
A woman undergoing chemotherapy for breast cancer developed fulminant liver failure after clinicians failed to check whether she had a history of hepatitis.
The Dropped "No"
with commentary by Annette J. Johnson, MD, MS
When a hospitalized man developed an arrhythmia, the night float resident checked a radiology report that stated the patient had a DVT. Intervention was started based on that assumption. However, the radiology report had been transcribed incorrectly.
Duty to Disclose Someone Else’s Error?
with commentary by Thomas H. Gallagher, MD
Transferred to a tertiary hospital, a child with severe swelling of the brain is found to have venous sinus thromboses and little chance of survival. Further review revealed that the referring hospital had missed subtle signs of cerebral edema on the initial CT scan days earlier, raising the question of whether to disclose the errors of other facilities or caregivers.
with commentary by Christopher Roy, MD
A week after successful pacemaker placement, an elderly man developed chest pain and was admitted to the hospital without having an urgent echocardiogram. Although providers felt that he "looked fine," the patient became acutely hypotensive, developed ventricular tachycardia and pulseless electrical activity, and required emergent resuscitative measures for cardiac tamponade.
with commentary by Caprice C. Greenberg, MD, MPH
Following an appendectomy, an elderly man continued to have right lower quadrant pain. Reviewing the specimen removed during the surgery, the pathologist found no appendiceal tissue. The patient was emergently taken back to the OR, and the appendix was located and removed.
Acute Respiratory Arrest in Pregnancy
with commentary by Baha Sibai, MD
A woman with chronic hypertension developed undiagnosed preeclampsia during pregnancy with twins. At 38 weeks, she experienced respiratory and cardiac arrest. Although she eventually recovered, the infants were stillborn.
Defensive Medicine: "Glowing" with Pain
with commentary by Manish K. Sethi, MD
Over the course of 2 years, a patient who frequently came to the emergency department complaining of abdominal pain underwent 12 CT scans of the abdomen and pelvis. All of them were completely normal.
Adolescent Diabetes: A Routine Visit?
with commentary by Gail B. Slap, MD, MSc
An overweight teenaged girl came to the pediatrics clinic for routine follow-up of her type 2 diabetes, complaining of nonspecific, intermittent abdominal pain and worsening acne. The physician prescribed topical acne cream and increased her diabetes medications. The next day, an obstetrician notified the pediatrician that this patient had delivered a healthy infant via Caesarian section overnight.
"Superficial" Report Leads to "Deep" Problem
with commentary by Gurpreet Dhaliwal, MD
Physicians confuse the terminology on a preliminary radiology report and diagnose a woman with foot and ankle pain as having a low-risk case of superficial vein thrombosis, rather than the more dangerous deep vein thrombosis she actually had.
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