WebM&M Cases & Commentaries

After an emergency department (ED) physician interpreted results of a point-of-care ultrasound as showing stable low ejection fraction, some volume overload, and a mechanical mitral valve in place without regurgitation for a man with a history of congestive heart failure, end-stage renal disease, and mechanical mitral valve replacement who presented with shortness of breath, the patient was admitted with a presumed diagnosis of volume overload. Reassured by the ED physician's interpretation of the ultrasound, the hospitalist ordered no further cardiac testing. The patient underwent hemodialysis, felt better, and was discharged. Less than 12 hours later, the patient returned critically ill and in cardiogenic shock. An emergency transthoracic echocardiogram found a thrombosed mitral valve, which had led to acute mitral stenosis and cardiogenic shock.

Following a hysterectomy, a woman was discharged but then readmitted for pelvic pain. The radiologist reported a large pelvic abscess on the repeat CT scan, and the gynecologist took the patient to the operating room for treatment based on the report alone, without viewing the images herself. In the OR, the gynecologist could not locate the abscess and stopped the surgery to look at the CT images. She realized that what the radiologist had read as an abscess was the patient's normal ovary.

An older man with a history of heavy smoking and chest pain underwent a chest CT in the emergency department that showed no evidence of an aortic dissection on the preliminary read. Although the patient followed up soon thereafter with a new primary care physician, it was not discovered until several months later that a suspicious lung nodule had been spotted on the initial CT.

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.

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.

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.

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.

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.

After an hour of failed resuscitative efforts, a woman who collapsed in a market is pronounced dead in the emergency department (ED). Only later do the paramedics and physician discover a small bullet in the patient's chest.

A patient with metastatic cancer admitted for pain control develops acute shortness of breath. The overnight resident reads the CT as a large pulmonary embolism, but the next morning, the attending reads it differently.

Transferred from one hospital to another for urgent evaluation, a patient is initially misdiagnosed when the CD (containing her radiographs) sent with her displays the older, rather than current, CT scans first.

An ill physician arrives at the ED for evaluation of shortness of breath. As it is past midnight and he is the only radiologist around, he reads (and misinterprets) his own x-ray.

A central line placed incorrectly causes a patient to suffer permanent neurologic damage.

Trusting an incorrectly labeled chest x-ray over physical exam findings, a resident places a chest tube for pneumothorax in the wrong side.

A patient with chest pain is incorrectly diagnosed as having had an MI. Although physicians eventually realize the patient had an aortic dissection, it is too late. The patient dies.

A chest x-ray incorrectly read as pleural effusion, rather than lung collapse, leads to iatrogenic pneumothorax following thoracentesis.