RMF Teaching Case M2-1 - Download
The infant was born at 25 weeks gestational age, weighing 800 grams (approximately 1.76 lbs.). At birth, she was transferred to a neonatal intensive care unit where she required ventilator treatment for respiratory distress syndrome. She also developed a small intracranial hemorrhage and received an exchange transfusion for hyperbilirubinemia. On her 14th day, the infant underwent surgery to ligate a large vessel near her heart. She subsequently had an intracranial hemorrhage and developed seizures.
Four days later, she "inadvertently” received an intravenous infusion of 180 milliliters of hyperalimentation fluid over a 30-minute period. This overloaded her system, resulting in shock, acidosis, electrolyte abnormalities and increase seizure activity. Resuscitation efforts succeeded and exchange transfusions were done in an effort to correct fluid overload. Over the next few days, the infant went into acute renal failure and developed more severe cardiac abnormalities. One week after the incident, the infant arrested and died.
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RMF Teaching Case M2-2 - Download
Based on actual events drawn from RMF medical liability claims files, this 17-minute video tells the story of a healthy, pregnant woman, and the health care workers who treat her and her newborn child. As a result of a series of seemingly small but accumulating errors, the safety of the mother and her baby is tragically compromised.
RMF Teaching Case M2-3 - Download
Ms. Evans, a 32 year old patient of Dr. Muller, presented with complaints of a nodule in her left breast. A mammogram was ordered. The radiologist reported that the mammogram "reveals no evidence of malignancy or significant changes from the previous year's film."
Two years later, Ms. Evans returned to Dr. Muller for a routine physical. Dr. Muller noted fibrocystic changes in her left breast and ordered a biopsy. The results of the biopsy indicated infiltrating carcinoma. Reviewing the last film, Dr. Muller determines that changes were evident in Ms. Evans film from two years ago.
