Failure to prevent aspiration
A woman came to the ED with abdominal pain, nausea, and constipation.
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Failure to properly evaluate and treat depression
A 51-year-old man came to his primary care physician and reported insomnia.
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Improper administration of anesthesia and surgical awareness
A 34-year-old man was taken to the OR for a hernia repair.
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Failure to supervise advanced practice provider
A 40-year-old man with an 18-year history of migraine headaches came to his family physician.
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Improper prescribing following surgery
A 43-year-old man came to the emergency department (ED) on August 21 with sudden epigastric pain radiating to his back with severe nausea and vomiting.
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Failure to respond to abnormal liver function test results
A 60-year-old woman came to her primary care physician’s office with abdominal pain and fullness
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Failure to treat plagiocephaly in a timely manner
A woman brought her 10-month-old son to Pediatrician A’s office for evaluation of reported head asymmetry and earache.
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Failure to communicate diagnosis of ectopic pregnancy
A 26-year-old woman came to her ob-gyn after visiting the ED with pain in her right lower abdomen
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Failure to properly administer pain medication
A patient was being treated for chronic pain related to failed back syndrome
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Improper endotracheal tube placement
A 34-year-old man came to a hospital by EMS with shortness of breath and high blood pressure.
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Failure to treat suspected deep vein thrombosis
A man living in a nursing home reported right leg pain. Staff documented a 2+ edema in his right foot.
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Failure to diagnose Churg-Strauss Syndrome
A 44-year-old man came to the ED with leg swelling and bruising for the past six days.
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Failure to diagnose anemia
A 17-month-old girl was brought her pediatrician to complete vaccinations, a visit documented as “vaccines only.”
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Failure to confirm diagnosis of polycythemia vera
A 40-year-old man came to an internal medicine physician and reported feeling weak and tired.
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Failure to recognize esophageal intubation
A 51-year-old man was scheduled for a right knee replacement revision at a local hospital.
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Risk alert and closed claim study — Wernicke's Encephalopathy after bariatric surgery
The TMLT claims and risk management departments have seen an alarming increase in the number of claims filed related to Wernicke’s encephalopathy (WE) following bariatric surgery.
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Procedure performed when contraindicated
A 67-year-old man was referred to a gastroenterologist for a screening colonoscopy.
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Overprescribing NSAIDs
A 50-year-old man came to the ED with symptoms that suggested cellulitis.
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