On 6/23/2014, a 66-year-old male presented to the Physicians Regional Medical Center for gastric bypass surgery.
Following the gastric bypass procedure, on 6/24/2014, a radiologist performed a Gastrografin upper GI series on the patient to ascertain whether there was a leak or obstruction in the patient’s digestive tract. A leak of contrast material was visible on radiographic images obtained by the radiologist during the procedure; however, the radiologist failed to detect the leak in the patient’s digestive tract and reported a negative GI series. The patient was subsequently discharged from the hospital.
Approximately thirty hours after his discharge, the patient returned to the hospital suffering from abdominal pain and sepsis. It was discovered that the patient had a perforation in his digestive tract. During surgery to repair this perforation, the patient suffered cardiac arrest and anoxic brain injury. The patient ultimately expired as a result of these complications on 7/10/2014
The Board judged the radiologist’s conduct to be below the minimum standard of competence given his failure to detect a leak in the patient’s digestive tract during the performance of a Gastrografin upper GI series.
Date: December 2017
Diagnosis: Acute Abdomen
Medical Error: False negative
Case Rating: 3
Link to Original Case File: Download PDF
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