Table 2.

Description of cases that POCUS may have contributed to the M&M.

Case	Case description	Ultrasound contribution	Type of error
			Incorrectly interpreted	Incorrectly performed	Incorrectly integrated
1	Possible septic shock with acute on chronic RV failure.	Severe RV dysfunction correctly identified, however 4L of IVF given causing fluid overload.			X
2	Hemothorax. Liver injury occurred during chest tube placement.	Hemothorax correctly identified but ultrasound not used to guide chest tube placement.		X	X
3	Persistent tachycardia. PE not considered.	RV dilatation correctly identified but not incorporated into care.			X
4	Hemothorax after ultrasound-guided ipsilateral central line placement.	Presumed vascular injury secondary to central venous access attempt. Unclear how procedure was done.		X
5	Trauma with hypotension.	+FAST correctly identified. No surgery consults until after CT.			X
6	Leg infection treated as cellulitis as outpatient. Returned with necrotizing fasciitis.	Ultrasound correctly identified soft tissue edema, but providers missed subcutaneous air, which was visible.	X
7	Shortness of breath. Pleural and pericardial effusions identified, admitted.	Pericardial effusion correctly identified, but not read as early tamponade delaying emergent consults.	X
Total (8 errors/7cases)			25% (2/8)	25% (2/8)	50% (4/8)

M&M, morbidity and mortality; RV, right ventricle; IVF, intravenous fluid; PE, pulmonary embolism; FAST, focused assessment with sonography in trauma; CT, computed tomography.