This month we look at a situation where multiple errors, by different clinicians, led to the tragic and unnecessary death of a 20-year old college student.

Ms J was a junior in college studying computer science, working at the school’s library and a member of a sorority. She’d had a steady boyfriend for some time, so she and her mother, Mrs J, decided to visit Mrs J’s gynecologist to discuss birth control for Ms J.

At the appointment, the gynecologist, Dr H, noted that Mrs J had experienced multiple deep vein thrombosis (DVT) and pulmonary embolisms (PE) during her pregnancies. In order to determine whether Ms J was also at risk for blood clots, Dr H drew blood and ordered tests, and advised the mother and daughter to return in a month to discuss different contraceptive options.

The test for Factor V Leiden was positive for 1 copy of the Factor V Leiden mutation. The test results were returned to Dr H’s office, where they were reviewed and incorrectly interpreted as being all normal – when in fact the lab result for Factor V Leiden was “positive” – which is not a normal lab result. The results were entered into the computer as normal, and Ms J was never told about the mutation.

At the next appointment, the gynecologist prescribed hormonal birth control pills for Ms J, who began taking them without knowing that she was predisposed to an increased risk of blood clots. A month later, Ms J began feeling unwell. She went to her local urgent care and saw the physician on staff that day – Dr B. Ms J’s complaints included shortness of breath, chest pain, cough, headache and sore throat. Ms J told the physician that she was on birth control pills but did not mention the clotting mutation because she was unaware of it. She said she was unable to ride her bike to class due to the shortness of breath and had to take the bus places where she had easily walked before.

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The physician performed an exam and diagnosed Ms J with bronchitis. He prescribed an antibiotic and advised Ms J to return if she did not improve. 

It was finals time at the college, and Ms J was concerned about her upcoming tests and the fact that she still was not feeling better after a couple of days of taking the antibiotics. Two days after her initial visit to the urgent care clinic, she returned. The clinic was packed and understaffed, it being the height of flu season.