One case shown per specialty. Each carries the full set of failure modes for that field,
the cross-examiner's signature move, and the Rule 702 angles specific to it.
Accident Reconstruction
Simulation output not validated against physical evidence
PC-Crash, HVE or similar run to produce an animation, with no demonstration that the simulated rest positions, crush pattern and tire marks match what was actually documented
What witnesses actually say here“The software is industry standard — it does the physics for you.”
What the report has to establish: Validate the run against the physical evidence and say so on the record. An unvalidated simulation is a cartoon, and opposing counsel will call it one
10 failure modes tested in this specialty · also drilled: Crush analysis using another vehicle's stiffness coefficients
Anesthesiology
Difficult airway — no documented backup plan
Patient with predicted difficult airway (Mallampati 3-4, limited neck extension, prior intubation history) — chart shows no backup plan (LMA, video laryngoscope, awake fiber-optic, surgical airway)
What witnesses actually say here“She didn't look that hard to me — I figured we'd just do a standard induction.”
What the report has to establish: ASA Difficult Airway Algorithm requires a documented backup plan; chart it pre-induction
10 failure modes tested in this specialty · also drilled: Capnography not used in deep sedation
Cardiology + Electrophysiology
STEMI door-to-balloon >90 min
STEMI patient had door-to-balloon time exceeding the 90-minute ACC/AHA benchmark without documented systems-level explanation
What witnesses actually say here“The cath lab wasn't ready right away — there were some delays.”
What the report has to establish: Pre-depo know the exact door-in, ECG-acquisition, cath-lab-activation, and balloon-inflation times; have systems-explanation ready
18 failure modes tested in this specialty · also drilled: Aortic dissection — no CTA
Cardiothoracic Surgery
CABG mortality/stroke — STS risk-stratification missed
CABG patient with STS Risk Score >5% mortality risk; no documented risk-benefit discussion or alternative consideration (PCI, medical therapy)
What witnesses actually say here“I knew he was high risk but I felt CABG was his best option.”
What the report has to establish: STS Risk Score calculated + documented; high-risk patients require formal Heart Team discussion per AHA/ACC
8 failure modes tested in this specialty · also drilled: Post-op pericardial tamponade — recognition delay
Chiropractic
Cervical manipulation → vertebral artery dissection
High-velocity cervical thrust without VBI screening or informed consent specifically naming VAD/stroke risk; subsequent vertebrobasilar stroke
What witnesses actually say here“I do cervical adjustments routinely — I don't go through every theoretical risk.”
What the report has to establish: VBI screening (5Ds + 3Ns) documented + informed consent specifically naming VAD risk per ACA standards
6 failure modes tested in this specialty · also drilled: Post-manipulation cauda equina
Civil & Structural Engineering
Applied the current code, not the one in force
Opinion measures the structure against a code edition adopted after the project was permitted, without identifying the governing edition or the local amendments
What witnesses actually say here“It doesn't meet code — I checked it against the IBC.”
What the report has to establish: State the governing code edition and adopting jurisdiction on the record before any compliance opinion. Where the current code is stricter, say so and say why it is not the measure
10 failure modes tested in this specialty · also drilled: Compliance opinion with no load calculations shown
Dermatology
Missed melanoma — ABCDE not applied
Lesion meeting ABCDE criteria (asymmetry, border, color, diameter, evolution) reassured as benign without biopsy or dermoscopy documented
What witnesses actually say here“It looked like a benign seborrheic keratosis to me.”
What the report has to establish: ABCDE-positive lesion = biopsy or close-interval dermoscopy + photo documentation
8 failure modes tested in this specialty · also drilled: Biopsy path result — miscommunication
Economic Damages & Lost Profits
But-for projection with no historical baseline
Lost-profits model projects growth the business never achieved, with no anchor to its own audited historical performance, and no explanation for the departure
What witnesses actually say here“Management told me they were about to break out — I built the model on their projections.”
What the report has to establish: Tie every projection to the company's own historical results, or state plainly and on the record why history is not the right baseline here
10 failure modes tested in this specialty · also drilled: Adopted counsel-supplied assumptions without testing
Emergency Medicine
"Gut decision" framing
Witness characterizes the dispo as a "gut feeling" or "I just had a sense" rather than an evidence-based reasoning chain
What witnesses actually say here“It was more of a gut call — she just didn't look that sick.”
What the report has to establish: Replace gestalt language with explicit risk-stratification: "Based on the HEART/Wells/etc. risk stratification documented in the MDM..."
13 failure modes tested in this specialty · also drilled: Last-known-well not anchored
Endocrinology
DKA — aggressive fluid resuscitation (cerebral edema)
New-onset DKA with bolus + rapid maintenance fluids exceeding PECARN-FLUID / ISPAD; cerebral edema
What witnesses actually say here“She was dehydrated and I wanted to catch her up on fluids.”
What the report has to establish: PECARN-FLUID or ISPAD cautious fluid protocol; document the rate calculation
6 failure modes tested in this specialty · also drilled: Thyroid storm — diagnosis + multimodal therapy delay
Endodontics
File separation — non-disclosure
File fractured in canal; not disclosed to patient; treatment continued without specialist referral
What witnesses actually say here“I left the small fragment — I figured it wouldn't cause problems.”
What the report has to establish: File separation = immediate documented disclosure + endodontist referral if cannot be retrieved + treatment options discussion
6 failure modes tested in this specialty · also drilled: Perforation — recognition + repair
Family Medicine
Missed cancer screening (USPSTF)
Patient eligible for CRC, breast, lung, or cervical screening per USPSTF; chart shows no documented screening offer or refusal across multiple visits
What witnesses actually say here“We talked about it but she wasn't interested in a colonoscopy.”
What the report has to establish: USPSTF-eligible patient = documented offer of screening + outcome (accepted, refused, scheduled, completed) at each annual visit
9 failure modes tested in this specialty · also drilled: Abnormal result — no documented follow-up
Gastroenterology
Missed colorectal cancer — quality indicators not met
CRC found within 5 years of "negative" screening colonoscopy; chart doesn't document ADR, cecal intubation, or withdrawal time
What witnesses actually say here“It was a clean colonoscopy at the time — I don't have my ADR data for that month.”
What the report has to establish: Document cecal intubation, withdrawal time ≥6 min, bowel-prep quality (Boston BPS), adenoma detection rate at depo
7 failure modes tested in this specialty · also drilled: Perforation recognition delay
General Dentistry
Office sedation — monitoring gap
Patient died during in-office sedation without continuous capnography or appropriately trained personnel
What witnesses actually say here“We use IV sedation in the office — I was monitoring her clinically.”
What the report has to establish: Office sedation = capnography + emergency drugs + ACLS-trained personnel per ADA / AAOMS
7 failure modes tested in this specialty · also drilled: Ludwig's angina from dental abscess
General Surgery
Time-out skipped or abbreviated
Witness conceded the Universal Protocol time-out was not performed or was abbreviated
What witnesses actually say here“We did a quick time-out — I don't remember every step.”
What the report has to establish: Time-out is non-negotiable per ACS/AORN Universal Protocol; if it was abbreviated, never concede; clarify what specifically was confirmed
13 failure modes tested in this specialty · also drilled: Count-discrepancy unresolved at close
Hematology / Oncology
Chemotherapy dosing error
Chemotherapy dosed by wrong BSA, wrong regimen, or wrong drug; cumulative-dose limit exceeded (anthracycline cardiotoxicity)
What witnesses actually say here“I always check BSA — I'd have to look at the specific calculation for this patient.”
What the report has to establish: Standardized chemotherapy order entry; BSA verification; cumulative-dose tracking per NCCN
7 failure modes tested in this specialty · also drilled: Febrile neutropenia — empiric antibiotic delay
Infectious Disease
Necrotizing fasciitis — recognition delay
Pain out of proportion to exam, bullae, crepitus, gas on imaging; LRINEC score high; surgical debridement delayed
What witnesses actually say here“It looked like cellulitis — I started antibiotics and admitted.”
What the report has to establish: Suspected nec fasc = STAT surgical consult + broad antibiotics within hour; LRINEC documented
6 failure modes tested in this specialty · also drilled: Septic arthritis — missed
Internal Medicine / Hospitalist
Inpatient deterioration — no escalation
Rising NEWS or MEWS score, sustained tachycardia/hypotension/altered mental status — no rapid response or ICU consult
What witnesses actually say here“I was watching her closely but I didn't feel she needed ICU.”
What the report has to establish: Trending early-warning score requires documented escalation: rapid response activation, ICU consult, or clear rationale
8 failure modes tested in this specialty · also drilled: Premature discharge — abnormal vitals/labs
Nephrology
Severe hyperkalemia — incomplete management
K+ >6.5 with ECG changes; calcium gluconate + insulin/dextrose + albuterol + bicarb + binder not all initiated
What witnesses actually say here“I gave the insulin and dextrose but I was waiting on the calcium.”
What the report has to establish: Severe hyperkalemia with ECG changes = calcium gluconate STAT + insulin/D50 + bicarb + binder + dialysis-ready
6 failure modes tested in this specialty · also drilled: AKI recognition delay
Neurological Surgery
Wrong-level spine surgery
Spine surgery at incorrect level; no intraop fluoroscopy / level-marker confirmation documented
What witnesses actually say here“I counted from the sacrum and was confident I had the right level.”
What the report has to establish: Intraop fluoroscopy with marker + counted vertebrae documented; Universal Protocol time-out
8 failure modes tested in this specialty · also drilled: Missed epidural hematoma
Neurology
Last-known-well not anchored
Stroke patient — witness can't tell deposing counsel the LKW time, or chart doesn't anchor it to a specific hour
What witnesses actually say here“I think the family said the symptoms started in the morning sometime.”
What the report has to establish: LKW is the single most-important stroke datapoint; chart MUST anchor it; pre-depo memorize the case's LKW
10 failure modes tested in this specialty · also drilled: tPA window calculation wrong
Nursing (RN/NP/CRNA)
Failure to escalate — chain of command
Patient deterioration; RN did not escalate to charge / MD / rapid response; no documented attempt to reach physician
What witnesses actually say here“I called the doctor but didn't hear back — I figured I'd wait until rounds.”
What the report has to establish: Trending NEWS/MEWS = mandatory MD notification + escalation to rapid response if criteria met; document the chain
8 failure modes tested in this specialty · also drilled: CRNA airway / sedation complication
Obstetrics & Gynecology
EFM category misread
Witness called a Category II tracing "reassuring" or a Category III tracing "indeterminate" — directly contradicts NICHD 2008 three-tier system
What witnesses actually say here“The strip was reassuring — I wasn't concerned.”
What the report has to establish: Use NICHD language verbatim: Category I reassuring, Category II indeterminate, Category III abnormal/predictive of acidemia. Never freelance the category names.
13 failure modes tested in this specialty · also drilled: Late-C-section retrospective concession
Ophthalmology
Retinal detachment recognition delay
New floaters, flashes, peripheral curtain in patient; not seen within hours; macula-off detachment
What witnesses actually say here“She called about flashes — we scheduled her for the next day.”
What the report has to establish: New floaters/flashes/curtain = same-day dilated exam; macula-on RD = emergent OR
8 failure modes tested in this specialty · also drilled: Post-cataract endophthalmitis recognition
Optometry
Retinal detachment recognition delay
Patient with new floaters/flashes/curtain; no same-day dilated exam or urgent ophthalmology referral; macula-off
What witnesses actually say here“I scheduled her for next week's appointment.”
What the report has to establish: New floaters/flashes/curtain = same-day dilated exam + STAT ophthalmology referral if positive findings
6 failure modes tested in this specialty · also drilled: Missed glaucoma — incomplete workup
Oral & Maxillofacial Surgery
Office sedation death
Patient died during in-office GA / deep sedation; capnography absent, emergency drugs not used appropriately, ACLS-trained personnel not present
What witnesses actually say here“I administered the anesthesia myself and was monitoring.”
What the report has to establish: Office GA/deep sedation = capnography + emergency drugs (succinylcholine, dantrolene if triggered) + ACLS personnel + reversal agents
6 failure modes tested in this specialty · also drilled: IAN injury — high-risk extraction
Orthodontics
External root resorption — excessive force
Severe external apical root resorption (>4mm); chart shows no periodic CBCT or force adjustment
What witnesses actually say here“She had some resorption but I continued treatment.”
What the report has to establish: Periodic root imaging during long treatment; force adjustment if resorption detected; pause treatment if severe
6 failure modes tested in this specialty · also drilled: TMJ disorder from treatment
Orthopaedic Surgery
Compartment syndrome missed
6 Ps (pain out of proportion, paresthesia, pallor, paralysis, pulselessness, poikilothermia) documented or evolving; no compartment-pressure measurement or fasciotomy decision documented
What witnesses actually say here“Her pain was a little out of proportion but I figured it was just post-op.”
What the report has to establish: Suspected compartment syndrome = serial compartment pressures or fasciotomy decision tree documented within the hour
8 failure modes tested in this specialty · also drilled: Wrong-level spine surgery
Otolaryngology (ENT)
Missed head/neck cancer — persistent symptoms
Persistent hoarseness >3 weeks, neck mass, dysphagia, or ear pain in adult smoker/drinker; no laryngoscopy or imaging documented
What witnesses actually say here“I gave him a steroid and reassessed in 6 weeks.”
What the report has to establish: Persistent ENT red-flag symptom in at-risk adult = laryngoscopy + imaging within weeks
8 failure modes tested in this specialty · also drilled: Post-tonsillectomy bleed — emergency mgmt
Pediatrics
Febrile infant <60d — no sepsis workup
Infant under 60 days with fever (≥38.0°C) discharged without full sepsis workup (CBC, blood culture, UA/urine culture, LP per protocol)
What witnesses actually say here“He looked well in the office — I told mom to bring him back if the fever didn't break.”
What the report has to establish: AAP 2021 febrile-infant guideline + Rochester/Step-by-Step/PECARN criteria; chart the algorithm applied
10 failure modes tested in this specialty · also drilled: Bacterial meningitis as "viral"
Periodontics
IAN injury — implant placement
Implant placed too close to or impinging on IAN/mental nerve; no CBCT or safety margin
What witnesses actually say here“I planned with the PA radiograph — I usually have enough bone.”
What the report has to establish: Implant near IAN = pre-op CBCT + 2mm safety margin + surgical guide; immediate referral if injury suspected
6 failure modes tested in this specialty · also drilled: Missed periodontal disease
Physical Therapy
Cervical manipulation — neurovascular injury
High-velocity low-amplitude cervical thrust without screening for VBI red flags; vertebral artery dissection
What witnesses actually say here“I always screen for red flags — I don't always write out each one.”
What the report has to establish: Pre-cervical-thrust screening: 5Ds + 3Ns (Dizziness, Drop attacks, Diplopia, Dysarthria, Dysphagia + Nausea, Numbness, Nystagmus); document the screening
7 failure modes tested in this specialty · also drilled: Medical red flags missed
Plastic Surgery
BBL — intramuscular fat injection (fat embolism)
BBL with documented or suspected intramuscular fat injection contrary to ASPS recommendation; fat embolism death
What witnesses actually say here“I tried to stay subcutaneous but it can be hard to be sure.”
What the report has to establish: BBL = subcutaneous-only fat injection per ASPS 2019 statement; never intramuscular gluteal injection
7 failure modes tested in this specialty · also drilled: Office-based anesthesia complication
Podiatry
Diabetic foot ulcer — amputation
Diabetic foot ulcer not staged per IWGDF (PEDIS/SINBAD); no documented offloading, vascular assessment, or wound care escalation; amputation
What witnesses actually say here“I gave her wound care instructions — she didn't come back for follow-up.”
What the report has to establish: Diabetic foot ulcer = IWGDF staging + offloading + vascular assessment + wound care plan + diabetes optimization
6 failure modes tested in this specialty · also drilled: Charcot arthropathy — missed
Psychiatry
No structured suicide-risk assessment
Patient with documented suicidal ideation; no Columbia Suicide Severity Rating Scale (C-SSRS) or SAFE-T documented
What witnesses actually say here“I assessed her clinically — she didn't seem like a suicide risk to me.”
What the report has to establish: Every patient with SI requires a structured risk assessment (C-SSRS preferred); document risk factors + protective factors
8 failure modes tested in this specialty · also drilled: Premature discharge of suicidal patient
Pulmonology / Critical Care
ARDS — high tidal volumes
ARDS patient ventilated at TV >6 mL/kg PBW or plateau pressure >30 cmH2O contrary to ARDS Network protocol; ventilator-induced lung injury
What witnesses actually say here“I was using 8 mL/kg — I find patients tolerate it better.”
What the report has to establish: ARDS = low-TV ventilation per ARDS Network: 6 mL/kg PBW, Pplat ≤30, FiO2/PEEP per table
7 failure modes tested in this specialty · also drilled: Central-line complication — recognition delay
Radiology
Missed cancer on imaging
Tumor visible in retrospect on prior imaging that radiologist reported as normal; satisfaction-of-search bias on follow-up study
What witnesses actually say here“Looking at it now, I can see the nodule, but the conspicuity at the time was low.”
What the report has to establish: Pre-depo know the specific lesion visible on the prior; characterize SOC engagement (peer-reviewed miss-rate literature)
8 failure modes tested in this specialty · also drilled: Critical finding — no direct communication
Rheumatology
Missed GCA — vision loss
New-onset headache + jaw claudication + age >50; ESR/CRP not checked OR steroids delayed; permanent vision loss
What witnesses actually say here“I wanted to confirm with biopsy before starting steroids.”
What the report has to establish: Suspected GCA = empiric high-dose steroids immediately + ESR/CRP + temporal artery biopsy; never delay steroids for biopsy
6 failure modes tested in this specialty · also drilled: Biologic — PJP / opportunistic infection
Urology
Ureteral injury — intraop not recognized
Ureteral injury during pelvic surgery (GYN, colorectal, urology) not recognized intraoperatively; recognized days later with urinoma/sepsis
What witnesses actually say here“I didn't suspect ureteral injury during the case.”
What the report has to establish: Intraop cystoscopy or stent placement for at-risk pelvic surgery; document the integrity check
8 failure modes tested in this specialty · also drilled: Missed/delayed prostate cancer — PSA mismanaged
Vascular Surgery
AAA leak/rupture — recognition delay
Patient with abdominal/back pain + hypotension + known or suspected AAA; CTA not obtained STAT; rupture progressed
What witnesses actually say here“He had back pain — I thought it was musculoskeletal.”
What the report has to establish: Abdominal/back pain + hypotension + AAA risk = STAT CTA + emergent vascular surgery
7 failure modes tested in this specialty · also drilled: Acute limb ischemia — revascularization delay