Table 3

Summary of 114 mistakes and outcomes reported by house officers

ErrorPatient outcome
AIDS=acquired immunodeficiency syndrome; ICU=intensive care unit.
Diagnostic errors
Misdiagnosed hypertension-induced pulmonary edema as pleural effusionNone
Failed to diagnose cryptococcoma on roentgenogramDeath
Possibly failed to diagnose AIDS adrenal insufficiencyDeath
Failed to diagnose small bowel obstruction in a patient with ascitesDeath
Missed physical findings because of concentration on abdomenNone
Failed to diagnose gastrointestinal bleedingDeath
Failed to place a nasogastric tube and to diagnose gastrointestinal bleedingStroke
Did not check chest roentgenogram in a patient with pneumothoraxDelayed diagnosis
Failed to recognize signs of cardiac disease in a patient with AIDS-related complexDelayed treatment
Misread electrocardiogram and treated a patient with verapamilHypotension
Failed to note acidosis in a hypotensive patient after a procedureNone
Failed to recognize tension pneumothorax at cardiac arrestDeath
Failed to examine and diagnose pneumothorax in an intubated patientDelayed therapy
Failed to diagnose eclampsiaDeath
Misdiagnosed ovarian cyst as pelvic inflammatory diseaseNone
Missed signs of sepsis in an elderly woman after an invasive procedureNone
Failed to examine and diagnose fracture in a “crack” cocaine userDelayed treatment
Did not recognize respiratory acidosisDeath
Failed to diagnose hypoxia in an agitated AIDS patientDelayed therapy
Did not examine and failed to diagnose cavernous sinus syndromeDelayed diagnosis
Failed to consider tension pneumothorax at cardiac arrestDeath
Failure to diagnose sepsis in a lung cancer patientDeath
Missed hemothorax on chest roentgenogramDeath
Did not consider right ventricular infarct during cardiac arrestDeath
Failure to notice neurological disease in an asthmatic outpatientDelayed diagnosis
Missed electrocardiogram changes in an elderly woman with back painDelayed care
Failed to order arterial blood gas tests and to recognize diabetic ketoacidosisDelayed treatment
Failed to diagnose cholangitis and impending sepsisDelayed treatment
Presumed a diagnosis of Pneumocystis carinii pneumonia in a patient with sepsisDeath
Treated cardiac disease as sepsis and induced congestive heart failureDeath
Did not recognize falling partial thromboplastin time as a sign of recurrent pulmonary embolismDeath
Failed to collect sputum and to diagnose tuberculosisDisseminated tuberculosis, death
Misdiagnosed tubal pregnancy as ulcer diseaseNone
Missed electrocardiogram changes and failed to diagnose acute myocardial infarctionNone
Failed to diagnose atypical vertebral aneurysmNone
Failed to do lumbar puncture and to diagnose cryptococcal meningitisDeath
Misinterpreted coagulation studyOverdose of sodium warfarin
Failed to obtain correct chief complaint of headache before dialysisDeath
Errors in evaluation and treatment
Conservative treatment of an overdose of sodium warfarinHematoma
Inadequate evaluation of status of gastrointestinal bleedingTransfer to ICU
Failed to administer nitroprusside in aortic dissectionDeath
Failed to perform anticoagulation in a patient with cardiomyopathyStroke
Delayed antibiotic therapy in a patient with ascitesDeath
Delayed central line placementProlonged stay
Slow response to a call to see a patient after a liver biopsySurgery
Insufficient fluids administered to a patient with probable pancreatitisHypotension, transfer to ICU
Failed to treat hypoglycemia in AIDSFatal seizure
Did not evaluate decreased urine output in a patient receiving chemotherapyDrug toxicity
Delayed penicillin treatment of suspected meningococcus infectionNone
Delayed electrocardiogram in a patient with possible myocardial infarctionTransfer to ICU
Did not consider thrombolytic therapy in a patient with acute myocardial infarctionPossible loss of myocardial function
Failed to treat an episode of ventricular tachycardia in chronic obstructive pulmonary diseaseNone
Failed to treat coronary artery disease in a patient with vasculitisDeath
Misinterpreted admission arterial blood gas result in pneumoniaDeath
Delayed seeing a patient with acute congestive heart failureNone
Failed to make a timely evaluation of hypotension in an AIDS patientDeath
Removed Foley catheter too early from transplantation patientNone
Induced renal failure and congestive heart failure during workup of a hypoglycemic seizureDeath
Hesitated to perform a brain biopsy in an AIDS patientDelayed treatment
Incomplete débridement of a diabetic foot ulcerAmputation
Treated malignant hypertension on the ward instead of in the ICUStroke
Scheduled a treadmill test for a patient before ruling out myocardial infarctionRisked extending infarct
Errors in prescribing and dosing
Prescribed nonsteroidal anti-inflammatory agents for a patient with renal insufficiencyWorsened renal function
Nearly gave an overdose of labetalolNone
Prescribed a relative overdose of glyburideHypoglycemia
Failed to decrease the verapamil dose for renal functionFatal cardiac toxicity
Wrote a prescription for an overdose of phenytoinHospitalized for toxicity
Gave indomethacin to a dehydrated patientRenal failure
Failed to check the salsalate levelRenal failure, dialysis
Gave an extra dose of sustained-release verapamil for hypertensionHeart block, pacemaker
Gave esmolol to a patient after a myocardial infarctionPersistent bradycardia, extended infarct
Wrote a prescription for 10 times the correct dose of intravenous heparinNone
Gave a cancer patient an overdose of narcoticsRespiratory failure, transfer to ICU
Did not read syringe and gave 50 times the correct dose of levothyroxineNone
Failed to notice an elevated creatine kinase value in a patient receiving lovastatinMyalgia
Gave an overdose of intrathecal amphotericinNone
Inadvertently discharged a patient without nitroglycerinReadmission
Forgot to order potassium replacement for a patient after a myocardial infarctionDeath
Ordered potassium via bolus instead of slow infusionNone
Failed to notice an intern’s incorrect insulin orderHypoglycemia
Failed to notice an intern’s incorrect order for verapamilDeath
Ordered phenothiazine for haloperidol overdoseNone
Treated 4-year-old with tetracycline for a dog bitePossible tooth staining
Prescribed verapamil to a patient receiving beta-blocker therapyNone
Inadvertently stopped asthma medication at the time of hospitalizationRespiratory failure, transfer to ICU
Increased the rate of insulin drip unaware that the concentration had been changedHypoglycemia
Treated hypokalemia with oral replacementFatal arrhythmia
Insufficient potassium replacement in a patient receiving amphotericinDeath
Incorrect dosing interval for antibioticNone
Prescribed lorazepam to a patient with respiratory muscle weaknessDeath
Wrote a prescription for an overdose of gentamicin (not given)None
Ordered 10 times the correct dose of levothyroxineProlonged hospital stay
Exacerbated ICU psychosis with lorazepamMyocardial infarction
Gave captopril to a patient with a documented allergyNone
Gave ampicillin to a patient allergic to penicillinRash
Procedural complications
Failed to heed a suggestion to reposition central venous catheterEndocarditis
Removed pulmonary artery catheter with the balloon inflatedSmall amount of bleeding
Pneumothorax from central lineChest tube placed
Unable to place central lineMissed antibiotic doses
Blood return during lumbar punctureNone
Pneumothorax during thoracentesisChest tube placed
Perforated bowel during paracentesisChange in therapy
Lacerated liver during liver biopsyDeath
Perforated subclavian vein during central line placementDeath
Induced hemoptysis during thoracentesisNone
Placed central line without a follow-up roentgenogramFatal tension pneumothorax
Perforated ventricle during pacemaker placementDeath
Faulty communication
Failed to note incorrect arterial blood gas reading by internPremature discharge
Failed to follow the attending physician’s protocol for gastrointestinal bleedingNone
Failed to obtain consent before central line placementNo informed consent for a procedure that had a fatal complication
Accepted misinformation that the patient was not to be resuscitatedDeath
Failed to document “do not resuscitate” order in chart and failed to inform spouseResuscitation was performed against the patient’s wishes
Did not assert authority in resuscitation with questionable intubationDeath