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The Reporter November-December 2000

December 11, 2000

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Patient satisfaction: A measure of risk management success; The management of medication samples; Failure to perform a physical assessment

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Failure to monitor thiamine levels

A 50-year-old woman consulted with a bariatric surgeon for weight reduction surgery. The patient was 5’ 4” and weighed 265 pounds.

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Failure to diagnose cornual pregnancy

A 33-year-old woman came to the emergency department (ED) complaining of bilateral abdominal pain, back pain, and shortness of breath.

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Failure to insist on EMS transport

At 8:30 a.m., a patient’s wife called her husband’s family physician and requested an appointment because her husband was experiencing chest pain that began the previous evening.

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Failure to diagnose rhabdomyolysis

At 3:20 p.m., a 3-year-old girl was brought to the emergency department (ED) with complaints of fever, lethargy, sore throat, severe leg pain bilaterally with decreased sensation, and absent reflexes.

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Failure to monitor patient’s postoperative INR

A 54-year-old woman came to an orthopedic surgeon with complaints of chronic bilateral hip pain lasting for 30 years.

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Failure to properly supervise

A 28-year-old woman came to an orthopedic clinic with right hip pain lasting for two weeks. Orthopedist A’s physician’s assistant (PA) examined the patient and obtained x-rays.

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Failure to evaluate patient

A 72-year-old man was evaluated by Ophthalmologist A on several occasions. The patient had cataracts, with best corrected visual acuity of 20/25 in the right eye and 20/40 in the left eye.

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Negligence in placing incorrect lens

A 59-year-old man came to his ophthalmologist complaining of ongoing visual problems. He had a long, complicated history that included uveitis, inflammation, and glaucoma.

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Improper performance — cataract surgery

A 63-year-old man came to Ophthalmologist A complaining of visual changes to both eyes. He had a history of bilateral cataracts.

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Failure to properly perform surgery

A 45-year-old woman came to her ob-gyn for complaints of heavy bleeding and pelvic pain. The patient’s history included pelvic inflammatory disease, a bilateral tubal ligation, and myomectomy.

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Failure to discontinue medication

A 34-year-old woman came to an ob-gyn for prenatal care on May 25. This was the patient’s fifth pregnancy.

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Failure to diagnose breast cancer

A 49-year-old African-American woman came to an internal medicine physician in August 2001. She continued to see this physician and his physician’s assistant for several years.

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Failure to order appropriate treatment

On December 3, a 27-year-old woman came to the office of Internist A. The patient reported abdominal pain.

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Failure to diagnose and treat thrombosis

A 66-year-old man came to his internist with complaints of shortness of breath and chest pain that had been present for three to four weeks.

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Failure to properly manage resuscitation efforts

An 8-year-old girl with a history of a congenital bicuspid aortic valve and aortic stenosis was in need of restorative dental work for dental decay/cavities.

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Failure to order chest x-ray

A 68-year-old woman residing at an assisted living facility was having syncopal episodes that resulted in falls with minor head trauma.

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Vision loss following surgery

A 41-year-old woman was referred to an orthopedic surgeon. She had a history of progressive lumbar scoliosis secondary to spasticity from congenital diastematomyelia.

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