1. Baby Death caused by Failure to Monitor (Allegheny County)
A full term baby was born with Apgars of 7 and 8 but within 6 hours developed respiratory distress. He was diagnosed with a spontaneous pneumothorax and was transferred to the neonatal intensive care unit (NICU). He required 100% oxygen. He was weaned to room air after approximately 24 hours. After being removed from the oxygen, he began to get fussy, most likely because he was hungry. Approximately 12 hours later, he was found with a very low heart rate. He was blue and not breathing. No alarms had gone off. Attempts were made to resuscitate him but the breathing tube was placed in his stomach instead of his airway. They were unable to resuscitate him and he died. No monitors were on and the baby became distressed and suffocated without the nurses knowing. When the baby was discovered, it was too late to revive him.
2. Baby death after removal of only kidney (Allegheny County)
A pregnant woman had a prenatal ultrasound that showed her baby had a multi-cystic right kidney and no left kidney. On two subsequent ultrasounds there was a “probable” left kidney. Two subsequent ultrasounds did not visualize a left kidney but still stated probable left kidney.
After birth, the baby was diagnosed with an esophageal fistula and an abdominal obstruction. He was producing urine and his kidney blood tests were normal. An abdominal ultrasound was ordered but not done. At the time of surgery to repair the fistula and abdominal obstruction, the surgeon observed the multi-cystic kidney and asked a nephrologist to assess the status of the kidney. The nephrologist told the surgeon that the kidney was not functioning and the surgeon removed the kidney.
Postoperatively, the baby became unstable and an ultrasound revealed that he had no left kidney. The surgeon had surgically removed his only functioning kidney; since dialysis was not an option, he died several days later.
3. Baby injury in Neonatal Intensive care unit (Allegheny County)
Twin girls were born prematurely at 30 weeks gestation. After being resuscitated, they were transferred to the neonatal intensive care unit (NICU). Approximately 4 hours after birth, Twin A was found to have an injury to her left index finger. This had not been present at birth. The injury developed into a large scar and after discharge from the hospital, the injured baby went to her pediatrician who ordered an x-ray. The x-ray showed a fractured proximal interphalangeal joint on her left index finger. In spite of surgery to repair the joint, the finger is permanently shorter than the other fingers and has no motion in the PIP joint. This injury occurred when the baby was in the complete control of the hospital personnel.
4. Failure to repair Abdominal Aortic Aneurysm (Allegheny County)
A 65-year-old man was experiencing abdominal and flank pain and went to the Emergency Room. A CT scan showed a 10 cm abdominal aortic aneurysm (AAA). He was lifeflighted to a tertiary care center for vascular surgery. On arrival, another CT scan confirmed the AAA. Despite the man having no risk factors for coronary artery disease, the vascular surgeon ordered an expedited cardiac consultation. The consultation did not take place until 12 hours later and the cardiologist recommended an Adenosine SPECT stress test that could not be done for 2 days. The following day the aneurysm ruptured requiring emergency surgery. Because the surgery was done emergently, he developed isehemic bowel resulting in short gut syndrome, acute tubular necrosis, pneumonia, sacral decubitus ulcer, abdominal wound infection, sepsis and he also suffered an anoxic brain injury. He died several weeks later.
5. Failure to inform and treat after abnormal kidney function studies resulting in a kidney transplant (Allegheny County)
A 46-year-old man went to the hospital for a breathing problem. During his hospitalization, blood work was done that showed that his kidney function levels were very high indicating poor kidney function. The attending doctor did not notify him of these results or follow up on them.
Six months later he was to undergo a CT scan with contrast and blood tests were done prior to the CT Scan. These tests revealed that his kidney function levels were even higher than they had been 6 months prior. Despite treatment, the kidney damage was so severe that he ultimately required and received a kidney transplant.
6. Failure to Diagnose and treat chickenpox pneumonia with antiviral medication resulting in a leg amputation. Antibiotics not effective. (Mercer County)
A 20-year-old man went to the Emergency Room with complaints of chest pain, breathing difficulties and a rash. He had been exposed to a niece with chickenpox. An xray revealed pneumonia. An arterial blood gas showed that he was compensating for his poor breathing. The Emergency Room physician diagnosed him with chickenpox and pneumonia. He was given antibiotics and sent home.
The following day he returned to the Emergency Room with complaints of getting worse. His breathing rate and heart rate were even higher than the day before but no further testing was done and he was sent home.
The following day his breathing became worse and his left leg became cool and pale. Upon returning to the ER, his oxygen level was very low and his left leg had no pulses below the knee. The patient was diagnosed with chickenpox pneumonia and an arterial clot in his leg. He was taken for emergency surgery to remove the clot in the artery in his leg. This was unsuccessful and he was transferred to a tertiary care center. The physicians tried to save his leg but he ultimately he required an above the knee amputation of his left leg and partial amputation of his right foot. Given that chickenpox is a virus, the antibiotic he was given for his pneumonia was useless. Antibiotics are only effective for bacterial infections. He should have been given an antiviral medication, Acyclovir, not antibiotics. Because he was not given the appropriate treatment for his chickenpox, he suffered a complication of the untreated chickenpox that resulted in his losing his leg.
7. Failure to properly treat hyponatremia (low sodium) and hypokalemia (low potassium) resulting in Central Pontine Myelinolysis (CPM). (Monongalia County West Virginia)
A 52-year-old man had a near fainting episode in the bathroom and was lifeflighted to a University Hospital. In the Emergency Room he was found to have very low sodium (hyponatremia) and low potassium (hypokalemia) levels. He was also in acute renal failure. He was admitted to the hospital and treated for his low sodium and low potassium. However, his sodium was raised too quickly. He was discharged 5 days later. Two days after discharge he was having mental confusion, inaudible speech and tremors. He was first taken to a local hospital and then transferred back to the University hospital. He was ultimately diagnosed with central pontine myelinolysis (CPM). CPM is brain damage that is caused by a too rapid correction of sodium. Upon transfer to a rehabilitation facility, he was non-ambulatory, non-verbal and he had no ability to take care of any of his daily needs. He was on a feeding tube. He was discharged from the rehabilitation center after a month of rehabilitation. He has long-term cognitive deficits and is on social security disability.
8. Antibiotic therapy resulting in Anaphylactic Reaction and Shock with Brain Damage (Forest County, PA)
A 20-year-old woman was prescribed an antibiotic and, shortly after taking it, she began to develop severe breathing difficulties. She returned home and her companion called 911 and began driving her to the hospital. On the way to the hospital an ambulance met them and she was not breathing. CPR was initiated and she was brought to the hospital. She was diagnosed with a severe anaphylactic reaction and was resuscitated at the hospital. However, she suffered a severe anoxic brain injury and is in a “locked in” state and requires 24-hour care.
The patient was historically atopic (allergic to other stimuli). The antibiotic had been found to have a higher risk of severe reaction than other antibiotics but (MANUFACTURER) failed to warn of risk.
9. Fall resulting from failure to properly support postoperative patient (Allegheny County)
An 80-year-old woman had surgery to repair a torn Achilles tendon. Five days after surgery, while being assisted to the bathroom, the nurse’s aide failed to properly support the patient and she fell to the floor opening up the surgical wound. She required emergency surgery to reclose the wound. She also needed to have leeches applied to the wound in order for it to properly heal. She required months of physical therapy and home nursing care.
10. Failure to Diagnose and Perform Additional Testing in Breast Cancer, Prostate Cancer and Lung Cancer
A 49-year-old woman with a family history of breast cancer had a mammogram that showed a mass. The breast cancer was not diagnosed until 18 months later because the physician did not follow up on the suspicious mass. (Mercer County)
A 62 year old with a family of breast cancer obtained yearly mammograms. She was diagnosed with breast cancer in 2008. However, in looking back at the 2006 and 2007 mammograms, they showed the beginnings of the cancer but the radiologist did not identify them. She had a 2-year delay in breast cancer diagnosis resulting in a mastectomy and radiation treatments. (Crawford County)
A 65-year-old man saw a urologist on a yearly basis. PSA levels were done and digital rectal examinations were done. For the first seven years there were no abnormalities in the digital rectal examination. However in 2000, a nodule was detected on the prostate but the urologist did no further testing. This hodule was present for the next three years. A biopsy was finally ordered and it revealed a Gleason 9 prostate cancer. Gleason 9 is cancer with a poor prognosis. The patient underwent a prostatectomy and a clinical trial of chemotherapy. (Allegheny County)
A 54-year-old man had a CT scan of the chest for symptoms of pain and a productive cough. The CT scan showed a lung mass. A biopsy revealed lung cancer. The patient underwent radiation treatments and subsequent removal of the lung mass. The surgeon recommended to the patients PCP to have him be seen by an oncologist for follow up radiation treatments. However, the surgeon did not advise the patient of this nor did he refer him to an oncologist. A year later a CT scan showed another lung mass. This was biopsied 3 months later and the biopsy revealed a recurrence of his lung cancer. He required additional radiation treatments. (Allegheny County)
11. Brain damage due to cardiac arrest from bleeding as a result of laceration of the aorta during surgery (Armstrong County)
A 38-year-old man underwent a laparoscopic Nissen Fundoplication to treat his severe gastroesophageal reflux. During the surgery, an arterial branch of the aorta began to bleed profusely. The surgeon decided to convert to an open procedure and called another surgeon to help him with the bleeding vessel. Upon opening the patient’s abdomen, there were 10 ounces of blood and clots of blood. After clearing the blood and clots, the bleeding stopped. The surgeons did not ligate or clip the vessel that had been bleeding. They only applied pressure and put on Avitene, a surgical type of collagen. A drain was also placed at the site. He was given several blood transfusions.
Early the following morning, the patient complained of severe spasms in his abdomen. The drain had a lot of blood in it and his heart rate was very high and he was unresponsive. He was taken back to the operating room and the site that had bled during the first operation was bleeding again. During the surgery to repair this bleeding site, the patient went into cardiac arrest. He was resuscitated but he suffered permanent brain damage as a result of the massive blood loss and cardiac arrest.
Although laceration of the aorta is a known complication of the fundoplication procedure, the surgeons did not properly repair the laceration and this resulted in permanent brain damage.
