An elderly lady with abdominal pain was seen twice and sent home, died of a missed small bowel obstruction
Sounds like a missed X-ray “wet read” by the ER physician: “Regardless of whether the X-rays were going to be subsequently reviewed by the radiology department, we think the miss on the part of Dr. — was an obvious one and ought not to have happened. Ultimately, his incorrect reading led him to develop an inaccurate working diagnosis of constipation.”
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