There were errors at every step in this sad case. It is unclear from the court record if it was the physician or a medical assistant or administrative assistant who entered the incorrect results of the clotting factor initially, but this was an error of huge magnitude. Because the gynecologist had wrong information, she prescribed hormonal birth control which would have been contraindicated if she had the correct test information. Once the gynecologist prescribed the birth control pill, she never warned the patient about the signs and symptoms of a pulmonary embolism, or what to do if she experienced any of these symptoms.
The first urgent care physician was aware that the patient was on hormonal birth control pills, and as a physician must have known that blood clots are a risk factor, but he did not connect the shortness of breath and chest pain with this, instead chalking it up to the common bronchitis. Knowing that she was on hormonal birth control, he should have evaluated her for a possible clot. When he sent her home with an antibiotic, he should have advised her to go to the hospital if the chest pain or breathing issues got worse.
Instead, she turned up again 2 days later with symptoms that should have alerted anyone that her condition was critical. Yet she was treated by a physician who did not even have access to her records and who by all accounts was overwhelmed by the number of patients in the clinic that day.
Had only one of these clinicians been more alert, the patient’s life might have been saved.