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Malpractice Case Studies Aren’t Just Somebody Else’s Troubles

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Malpractice Case Studies Aren’t Just Somebody Else’s Troubles

By Jock Hoffman, CRICO

Related to: Claims, Clinical Guidelines, Emergency Medicine, Primary Care, My Risk, Nursing, Obstetrics, Patient Safety Awareness, Publications, Surgery

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.

 

 
picture of couple sitting together

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.”

 

Case Type

Medical treatment

Responsible Service

Emergency Medicine

Outcome

Closed without payment

 
Man smiling in sun

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.

 

Case Type

Diagnosis

Responsible Service

General Medicine

Outcome

Closed with high-range payment ($500,000–$999,999)

 
Man holding a bag

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.

 

Case Type

Diagnosis

Responsible Service

General Medicine

Outcome

Closed with high-range payment ($500,000–$999,999)

 
granny sitting on bench

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.

 

Case Type

Medication

Responsible Service

General Medicine

Outcome

Closed with payment >$2.5M

 
young lady smiling outside

Surgery Change Needed Better 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).

 

Case Type

Surgery/
Communication

Responsible Service

Neurosurgery

Outcome

Closed with payment >$1M

 
Granny smiling

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.

 

Case Type

Patient Monitoring

Responsible Service

Nursing

Outcome

Closed with mid-range payment ($100,000–$499,999)

 
Older women smiling outside

EHR Error Exacerbates Adverse Event during IHT

Failure to monitor a patient's physiological status during intra-hospital transport.

 

Case Type

Intra-hospital Transfer

Responsible Service

Nursing

Outcome

Closed with high-range payment ($500,000–$999,999)

 
women looking outside

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.

 

Case Type

Obstetrics-related

Responsible Service

Obstetrics

Outcome

Closed with payment >$1M

 
man looking down

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.

 

Case Type

Medical Treatment

Responsible Service

Physiatry

Outcome

Closed with payment >$1M

 
Man smiling outdoors

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.

 

Case Type

Diagnosis

Responsible Service

Radiology

Outcome

Closed with payment >$2M

 

View more malpractice case studies or listen to some in podcast format.


January 31, 2022
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