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Let's go over some examples where

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missed findings happen,

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and that led to medical malpractice, uh, litigation,

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uh, which some are quite obvious and hard to defend, uh,

0:16

and, and some can be defended.

0:20

So this is a patient

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who was involved in a motor vehicular accident

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and head, head trauma.

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And obviously, uh, you have picked up on the finding

0:31

that there is, uh, non-displaced fracture,

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greater sphenoid wing fracture involving the

0:36

lateral wall of the orbit.

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Uh, there is a bit of, uh, pneumo, ence ephalus there,

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and then I don't know how well it projects on your end.

0:45

You can see a teeny tiny, uh, extra axial hemorrhage.

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And then there is some layering fluid within the, uh, uh,

0:54

sphenoid sinus right there.

0:56

Uh, this was read as no acute intracranial event

1:00

and the inflammatory changes within the sphenoid sinus

1:04

and the posterior ethmoid air cells by the,

1:07

the radiologist who was reading it.

1:09

So, uh, the ER saw this report and let the patient go home.

1:14

Two weeks later, the patient comes back to the hospital

1:18

with intractable headache, fever, and now neck rigidity.

1:21

So you already know where this is going.

1:24

Uh, you can see this is the head CT

1:27

that was obtained only two weeks later.

1:30

And you can see developing now. This is hydrocephalus.

1:33

There is transplantable flow of CSF.

1:35

There is cerebral edema.

1:37

There is some hyperdensity in the region

1:40

of the basilar tip right there.

1:42

And a CT angiogram was obtained.

1:44

And you can see this basilar tip aneurysm patient

1:47

unfortunately had meningitis, hydrocephalus, uh, had,

1:52

which led to development of a mycotic aneurysm.

1:56

And overall, what's not a good, uh, outcome for the patient,

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uh, in which the, the first initial, uh,

2:04

finding was, was missed.

2:06

So this is definitely a perceptual error or misdiagnosis.