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.
 | 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 | |
 | 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) | |
 | 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) | |
 | 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 | |
 | 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/ | Responsible Service Neurosurgery | Outcome Closed with payment >$1M | |
 | 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) | |
 | 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) | |
 | 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 | |
 | 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 | |
 | 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 | |
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View more malpractice case studies or listen to some in podcast format. | |||
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