Summary of 114 mistakes and outcomes reported by house officers
| Error | Patient outcome |
|---|---|
| AIDS=acquired immunodeficiency syndrome; ICU=intensive care unit. | |
| Diagnostic errors | |
| Misdiagnosed hypertension-induced pulmonary edema as pleural effusion | None |
| Failed to diagnose cryptococcoma on roentgenogram | Death |
| Possibly failed to diagnose AIDS adrenal insufficiency | Death |
| Failed to diagnose small bowel obstruction in a patient with ascites | Death |
| Missed physical findings because of concentration on abdomen | None |
| Failed to diagnose gastrointestinal bleeding | Death |
| Failed to place a nasogastric tube and to diagnose gastrointestinal bleeding | Stroke |
| Did not check chest roentgenogram in a patient with pneumothorax | Delayed diagnosis |
| Failed to recognize signs of cardiac disease in a patient with AIDS-related complex | Delayed treatment |
| Misread electrocardiogram and treated a patient with verapamil | Hypotension |
| Failed to note acidosis in a hypotensive patient after a procedure | None |
| Failed to recognize tension pneumothorax at cardiac arrest | Death |
| Failed to examine and diagnose pneumothorax in an intubated patient | Delayed therapy |
| Failed to diagnose eclampsia | Death |
| Misdiagnosed ovarian cyst as pelvic inflammatory disease | None |
| Missed signs of sepsis in an elderly woman after an invasive procedure | None |
| Failed to examine and diagnose fracture in a “crack” cocaine user | Delayed treatment |
| Did not recognize respiratory acidosis | Death |
| Failed to diagnose hypoxia in an agitated AIDS patient | Delayed therapy |
| Did not examine and failed to diagnose cavernous sinus syndrome | Delayed diagnosis |
| Failed to consider tension pneumothorax at cardiac arrest | Death |
| Failure to diagnose sepsis in a lung cancer patient | Death |
| Missed hemothorax on chest roentgenogram | Death |
| Did not consider right ventricular infarct during cardiac arrest | Death |
| Failure to notice neurological disease in an asthmatic outpatient | Delayed diagnosis |
| Missed electrocardiogram changes in an elderly woman with back pain | Delayed care |
| Failed to order arterial blood gas tests and to recognize diabetic ketoacidosis | Delayed treatment |
| Failed to diagnose cholangitis and impending sepsis | Delayed treatment |
| Presumed a diagnosis of Pneumocystis carinii pneumonia in a patient with sepsis | Death |
| Treated cardiac disease as sepsis and induced congestive heart failure | Death |
| Did not recognize falling partial thromboplastin time as a sign of recurrent pulmonary embolism | Death |
| Failed to collect sputum and to diagnose tuberculosis | Disseminated tuberculosis, death |
| Misdiagnosed tubal pregnancy as ulcer disease | None |
| Missed electrocardiogram changes and failed to diagnose acute myocardial infarction | None |
| Failed to diagnose atypical vertebral aneurysm | None |
| Failed to do lumbar puncture and to diagnose cryptococcal meningitis | Death |
| Misinterpreted coagulation study | Overdose of sodium warfarin |
| Failed to obtain correct chief complaint of headache before dialysis | Death |
| Errors in evaluation and treatment | |
| Conservative treatment of an overdose of sodium warfarin | Hematoma |
| Inadequate evaluation of status of gastrointestinal bleeding | Transfer to ICU |
| Failed to administer nitroprusside in aortic dissection | Death |
| Failed to perform anticoagulation in a patient with cardiomyopathy | Stroke |
| Delayed antibiotic therapy in a patient with ascites | Death |
| Delayed central line placement | Prolonged stay |
| Slow response to a call to see a patient after a liver biopsy | Surgery |
| Insufficient fluids administered to a patient with probable pancreatitis | Hypotension, transfer to ICU |
| Failed to treat hypoglycemia in AIDS | Fatal seizure |
| Did not evaluate decreased urine output in a patient receiving chemotherapy | Drug toxicity |
| Delayed penicillin treatment of suspected meningococcus infection | None |
| Delayed electrocardiogram in a patient with possible myocardial infarction | Transfer to ICU |
| Did not consider thrombolytic therapy in a patient with acute myocardial infarction | Possible loss of myocardial function |
| Failed to treat an episode of ventricular tachycardia in chronic obstructive pulmonary disease | None |
| Failed to treat coronary artery disease in a patient with vasculitis | Death |
| Misinterpreted admission arterial blood gas result in pneumonia | Death |
| Delayed seeing a patient with acute congestive heart failure | None |
| Failed to make a timely evaluation of hypotension in an AIDS patient | Death |
| Removed Foley catheter too early from transplantation patient | None |
| Induced renal failure and congestive heart failure during workup of a hypoglycemic seizure | Death |
| Hesitated to perform a brain biopsy in an AIDS patient | Delayed treatment |
| Incomplete débridement of a diabetic foot ulcer | Amputation |
| Treated malignant hypertension on the ward instead of in the ICU | Stroke |
| Scheduled a treadmill test for a patient before ruling out myocardial infarction | Risked extending infarct |
| Errors in prescribing and dosing | |
| Prescribed nonsteroidal anti-inflammatory agents for a patient with renal insufficiency | Worsened renal function |
| Nearly gave an overdose of labetalol | None |
| Prescribed a relative overdose of glyburide | Hypoglycemia |
| Failed to decrease the verapamil dose for renal function | Fatal cardiac toxicity |
| Wrote a prescription for an overdose of phenytoin | Hospitalized for toxicity |
| Gave indomethacin to a dehydrated patient | Renal failure |
| Failed to check the salsalate level | Renal failure, dialysis |
| Gave an extra dose of sustained-release verapamil for hypertension | Heart block, pacemaker |
| Gave esmolol to a patient after a myocardial infarction | Persistent bradycardia, extended infarct |
| Wrote a prescription for 10 times the correct dose of intravenous heparin | None |
| Gave a cancer patient an overdose of narcotics | Respiratory failure, transfer to ICU |
| Did not read syringe and gave 50 times the correct dose of levothyroxine | None |
| Failed to notice an elevated creatine kinase value in a patient receiving lovastatin | Myalgia |
| Gave an overdose of intrathecal amphotericin | None |
| Inadvertently discharged a patient without nitroglycerin | Readmission |
| Forgot to order potassium replacement for a patient after a myocardial infarction | Death |
| Ordered potassium via bolus instead of slow infusion | None |
| Failed to notice an intern’s incorrect insulin order | Hypoglycemia |
| Failed to notice an intern’s incorrect order for verapamil | Death |
| Ordered phenothiazine for haloperidol overdose | None |
| Treated 4-year-old with tetracycline for a dog bite | Possible tooth staining |
| Prescribed verapamil to a patient receiving beta-blocker therapy | None |
| Inadvertently stopped asthma medication at the time of hospitalization | Respiratory failure, transfer to ICU |
| Increased the rate of insulin drip unaware that the concentration had been changed | Hypoglycemia |
| Treated hypokalemia with oral replacement | Fatal arrhythmia |
| Insufficient potassium replacement in a patient receiving amphotericin | Death |
| Incorrect dosing interval for antibiotic | None |
| Prescribed lorazepam to a patient with respiratory muscle weakness | Death |
| Wrote a prescription for an overdose of gentamicin (not given) | None |
| Ordered 10 times the correct dose of levothyroxine | Prolonged hospital stay |
| Exacerbated ICU psychosis with lorazepam | Myocardial infarction |
| Gave captopril to a patient with a documented allergy | None |
| Gave ampicillin to a patient allergic to penicillin | Rash |
| Procedural complications | |
| Failed to heed a suggestion to reposition central venous catheter | Endocarditis |
| Removed pulmonary artery catheter with the balloon inflated | Small amount of bleeding |
| Pneumothorax from central line | Chest tube placed |
| Unable to place central line | Missed antibiotic doses |
| Blood return during lumbar puncture | None |
| Pneumothorax during thoracentesis | Chest tube placed |
| Perforated bowel during paracentesis | Change in therapy |
| Lacerated liver during liver biopsy | Death |
| Perforated subclavian vein during central line placement | Death |
| Induced hemoptysis during thoracentesis | None |
| Placed central line without a follow-up roentgenogram | Fatal tension pneumothorax |
| Perforated ventricle during pacemaker placement | Death |
| Faulty communication | |
| Failed to note incorrect arterial blood gas reading by intern | Premature discharge |
| Failed to follow the attending physician’s protocol for gastrointestinal bleeding | None |
| Failed to obtain consent before central line placement | No informed consent for a procedure that had a fatal complication |
| Accepted misinformation that the patient was not to be resuscitated | Death |
| Failed to document “do not resuscitate” order in chart and failed to inform spouse | Resuscitation was performed against the patient’s wishes |
| Did not assert authority in resuscitation with questionable intubation | Death |