The phrase “comedy of errors” describes a situation or drama in which one mistake follows another to a point of amusement for observers. In the case of a woman in New York State suffering from abdominal problems, the “comedy of errors” turned out to be deadly.

When the female patient (we’ll call her Amanda) sought treatment for unspecified abdominal problems, the first doctor she saw gave her a colonoscopy (an examination of the inside of the colon by use of a small camera inserted rectally). The doctor misread the results and diagnosed colon cancer. A CT scan did not confirm the diagnosis. This was the first series of mistakes.

A few days later, Amanda was admitted to the hospital with nausea and vomiting. The second doctor did not read her test results for himself and determine that since the cancer diagnosis was not supported by the CT scan, it should not be taken as a definite, correct diagnosis. He proceeded directly to surgery to remove part of the colon. This was the second series of mistakes.

The surgery found no cancer but instead, just stool matter. At this point, the surgeon went to read the test results for himself and then determined that a different kind of surgery was needed, and he obtained permission for this surgery from Amanda’s husband. He returned to surgery for the second procedure. The entire surgical process lasted from 8 A.M. until 6:30 P.M. And since Amanda also suffered from diabetes and heart problems, this surgery was a severe strain on her body. She died of cardiac arrest after the surgery had been completed.

In March 2009, the surgeon was placed on probation for two years. But Amanda lost her life needlessly because two doctors could not be trusted to follow the correct procedures for reading test results and acting in accordance with a verified, correct diagnosis.

Source: State of New York, Department of Health, In the Matter of Dr. Domingo Carlos Nunez, March 26, 2009, http://w3.nyhealth.gov/opmc/factions.nsf/cd901a6816701d94852568c0004e3fb7/db489a4d9ca69e94852573d9006a1dff/$FILE/ARB%20146968.pdf