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WebM&M: Case Studies

WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME. Commentaries are written by patient safety experts and published monthly.

Have you encountered medical errors or patient safety issues? Submit your case below to help the medical community and to prevent similar errors in the future.

This Month's WebM&Ms

Update Date: February 28, 2024
Have you encountered medical errors or patient safety issues?
Have you encountered medical errors or patient safety issues? Submit your case below to help the medical community and to prevent similar errors in the future.

All WebM&M: Case Studies (634)

Published Date
PSNet Publication Date
Displaying 1 - 20 of 634 Results
Christian Bohringer, MBBS and Linda Vo, MD| February 28, 2024

A 47-year-old obese man with hypertension fell and suffered a cervical spine (C5/C6) fracture. He was scheduled for urgent anterior cervical decompression and fusion and was transferred to the operating room (OR) where general anesthesia was induced. During the procedure, his expired tidal volume decreased from 560 ml to about 330 ml. He was manually ventilated through the endotracheal tube, which proved very difficult. An urgent chest X-ray did not reveal any pneumothorax. The Black Belt cervical retractor was released by the surgeon resulting in complete resolution of the airway obstruction. The commentary highlights the importance of vigilant monitoring and good communication to identify and respond to life-threatening events and describes approaches to improve crisis management during anesthesia events.

Timothy Do, BS and Fiona J Scott, MD, MPH, MS, MHI| February 28, 2024

A 32-year-old woman was admitted to the hospital for endoscopic retrograde cholangiopancreatography (ERCP) under monitored anesthesia care (MAC). As the endoscope was advanced into the stomach, the patient vomited. She was immediately turned supine but copious vomitus obstructed the suction catheter. The patient started to decompensate with decreasing oxygen saturation. The anesthesia team attempted to secure the airway by endotracheal intubation but was unable to place a tube due to poor view and vomitus. The patient went into cardiac arrest and ultimately passed away. The commentary discusses safety considerations for ERCP under MAC, weighing the risks and benefits of MAC versus general anesthesia, and airway management during emergencies.

Jazmin A. Wander, MD and David K. Barnes, MD, FACEP.| January 31, 2024

A woman presented to the emergency department (ED) for evaluation of a laceration to the palmer aspect of her left thumb. The treating clinician documented a superficial 3cm laceration and that the patient was unable to flex her thumb due to pain. The clinician closed the laceration with sutures. Neither a sensory examination nor wound exploration was documented. No fracture or foreign body was identified on x-ray but the procedure note did not mention whether the tendon was visualized. Several weeks after discharge from the ED, the patient was still unable to flex her thumb and was referred to an orthopedic surgeon and a hand specialist who surgically repaired a laceration to the flexor tendon. The commentary discusses the importance of including neurovascular and functional testing when evaluating hand injuries and the role of diagnostic imaging as well as strategies to improve diagnosis and mitigate human error when treating hand injuries.

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Kimberly Beres, DNAP, MHS, CRNA and Maria Cristina Gutierrez, MD | January 31, 2024

A patient presented for open reduction and internal fixation of a fractured radius under an ultrasound-guided supraclavicular brachial plexus nerve block. The initial attempt at local anesthesia using 2% lidocaine was inadequate, necessitating a subsequent lidocaine injection, followed by the procedural block using 20 ml of 0.375% plain bupivacaine. The patient developed progressive dyspnea and diminishing oxygen saturation, prompting emergent intubation and initiation of mechanical ventilation. The respiratory distress was traced back to an inadvertent injection of vecuronium (a neuromuscular blocking agent) instead of the intended local anesthetic during the initial attempt at brachial plexus nerve block. The commentary outlines approaches to improving perioperative safety, including the importance of safety culture, improving medication labeling and packaging, and using medication checks, checklists, and handoffs to reinforce professional provider responsibilities.

Jihey Yuk, MD and Julia Magana, MD | January 4, 2024

A 2-month-old boy was brought to the pediatric emergency department (PED) with a non-specific clinical picture of decreased responsiveness in the setting of a viral upper respiratory illness (URI) and appeared somnolent on initial evaluation. His pulmonary, cardiac, and abdominal examinations were unremarkable. He had normal muscle tone and movement of extremities and no bruising or abrasions were noted. Due to his persistently altered mental status, ultrafast magnetic resonance imaging (MRI) of the brain was obtained. Given limited overnight staffing, the MRI images were preliminarily read by a radiology resident. The patient was discharged with a parent after an “unremarkable” preliminary interpretation of the MRI. However, the next morning, the final reading of the MRI by the attending physician noted a small (5mm) subdural hemorrhage. The family was called back to the PED for further evaluation and a parent disclosed that the child had fallen off a bouncy seat placed on the bed, onto the floor, 3 days prior to presentation. The commentary discusses the pitfalls that clinicians encounter when they consider child abuse in the differential diagnosis and approaches to identifying non-accidental trauma (NAT) in pediatric patients.

A 9-year-old girl with cerebral palsy and epilepsy presented to the emergency department (ED) for increasing frequency of seizures lasting about 5 minutes, and developed hypoxic respiratory failure requiring endotracheal intubation, sedation, and mechanical ventilation. The pediatric neurology team ordered further testing, most of which had to be sent to an external laboratory and the results returned intermittently over several weeks. Several days into the hospital stay, acetylcholine receptor antibody test results returned markedly elevated at 302 nmol/L (normal is <0.5 nmol/L), which is concerning for myasthenia gravis. The laboratory finding that established this diagnosis was available in the electronic health record (EHR), but it was invisible to multiple teams of providers across multiple phases of care due to issues related to the EHR itself, challenges in clinical reasoning, and the workflow around transitions of care. The commentary highlights strategies to improve EHR systems to prevent diagnostic delays and care coordination for children with complex, chronic medical conditions

Berit Bagley, RN, MSN, CDCES, BC-ADM, Charity L. Tan, MSN, ACNP-BC, CDCES, BC-ADM, Deborah Plante, MD | November 30, 2023

A 67-year-old man with well-controlled type 2 diabetes mellitus underwent elective cardiac resynchronization and defibrillator device (CRT-D) implantation. The procedure was successful and he was discharged the next day with instructions to resume his prior medications, including empagliflozin. He presented to the emergency department the following day where he was diagnosed with euglycemic diabetic ketoacidosis (eDKA) and he was transferred to the intensive care unit (ICU) for insulin infusion. On further questioning, it was discovered that the patient had not been instructed to stop taking his empagliflozin three days before his elective cardiology procedure. He was told only to hold it on the day of the procedure, and to resume all medications after discharge; he carefully followed these instructions. 

Luciano Sanchez, PharmD and Patrick Romano, MD, MPH| November 30, 2023

An 81-year-old man was admitted to the intensive care unit (ICU) with a gastrointestinal bleed and referred for a diagnostic colonoscopy. The nurse preparing the patient for the colonoscopy mistakenly selected a jug of dialysis liquid rather than a polyethylene glycol solution commonly used to clean the colon for colonoscopy. When the barcode on the jug of dialysis liquid did not scan, the nurse called the hospital pharmacy for assistance and was provided a new barcode via a tube system. After the patient had difficulty drinking the solution, the nurse gave the rest of the liquid through a feeding tube bag. The medication mix-up was identified around midnight and the patient died about 7 hours later. 

Christian Bohringer, MBBS, and Sharon Ashley, MD | November 30, 2023

A 38-year-old woman with class 3 obesity required removed of a gastric balloon under general anesthesia. She required a relatively large dose of rocuronium for endotracheal intubation, and she was given intravenous sugammadex (200 mg) at the end of the procedure to reverse the neuromuscular block. A quantitative neuromuscular block monitor was not used, but reliance was placed on clinical signs. Shortly after arrival in the post-anesthesia care unit, she couldn’t move or open her eyes and became jittery with low oxygen saturation. Quantitative blockade monitoring revealed a “train of four” (TOF) ratio less than 70%, so she was given another 200 mg of intravenous sugammadex with return of normal motor function.

Rachel Ann Hight, MD, FACS | November 29, 2023

This case describes a 55-year-old woman who sustained critical injuries after a motor vehicle crash and had a lengthy hospitalization. On hospital day 30, a surgeon placed a percutaneous endoscopic gastrostomy (PEG) tube in the intensive care unit (ICU) after computed tomography (CT) scan showed no interposed bowel between the stomach and the anterior abdominal wall.  After the uncomplicated PEG placement, the surgeon cleared the patient’s team to advance tube feeds as tolerated. After several weeks of poorly tolerated tube feedings, the interventional radiology team reviewed a CT scan which had been obtained by another service 6 days after the PEG was placed and noted (for the first time) that the gastrostomy tube traversed the liver. Insufficient communication and fragmented care coordination across care settings contributed to poor management of the malpositioned PEG tube. The commentary underscores the importance of clear documentation of complications, highlights best practices to mitigate risks during patient care transition, and the importance of using multiple communication approaches to ensure appropriate continuity of care.

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Nidhi Patel Jain, PharmD, MBAc and David Dakwa, PharmD, MBA, BCPS, BCSCP | October 31, 2023

A 2-year-old girl presented to the emergency department (ED) with joint swelling and rash following an upper respiratory infection. After receiving treatment and being discharged with a diagnosis of allergic urticaria, she returned the following day with worsening symptoms. Suspecting an allergic reaction to amoxicillin, the ED team prepared to administer methylprednisolone. However, the ED intake technician erroneously switched the patient’s height and weight in the electronic health record (EHR), resulting in an excessive dose being ordered and dispensed. An automatic error message was generated due to the substantial difference from previous weights, but this message was overlooked by the ED technician and the data entry error was not detected or corrected. The commentary discusses the importance of verifying medication orders before administration, optimizing alert notifications to minimize the risk of alert fatigue, and the role of root cause analysis to identify factors contributing to medication error

This WebM&M describes two cases illustrating several types of Electronic Health Record (EHR) errors, with a common thread of erroneous use of electronic text-generation functionality, such as copy/paste, copy forward, and automatically pulling information from other electronic sources to populate clinical notes. The commentary discusses other EHR-based documentation tools (such as dot phrases), the influence of new documentation guidelines, and the role of artificial intelligence (AI) tools to capture documentation.

Hang Mieu Ha, DO and Kristin Alexis Olson, MD| October 31, 2023

A 32-year-old man presented to the hospital with a comminuted midshaft femoral fracture after a bicycle accident. Imaging suggested the fracture was pathologic and an open biopsy specimen was submitted to pathology for intraoperative consultation. However, this procedure was followed by a series of events that increased the likelihood for harm, including the inability to provide a definitive diagnosis at the time of frozen section examination, the subsequent delayed diagnosis, lack of cross coverage for leave among care team members, and poor communication and handoffs.

Leah Timbag, MD, MPH, Voltaire R. Sinigayan, MD, and Mithu Molla, MD, MBA | September 27, 2023

This case describes the failure to identify a brewing abdominal process, which over the span of hours led to fulminant sepsis with rapid clinical deterioration and eventual demise. The patient’s ascitic fluid cultures and autopsy findings confirmed bowel perforation, but this diagnosis was never explicitly considered. The commentary discusses the importance of early identification of sepsis, the role of biomarkers and risk scores in conjunction with bedside examinations to assess patients with suspected sepsis, and approaches to improve the prognosis of patients in septic shock, such as protocolized sepsis bundles.

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Commentary by James A. Bourgeois, OD, MD and Glen Xiong, MD | September 27, 2023

A 42-year-old man with a history of posttraumatic stress disorder (PTSD), alcohol use disorder and anxiety disorder, was seen in the emergency department (ED) after a high-risk suicide attempt by hanging. The patient was agitated and attempted to escape from the ED while on an involuntary psychiatric commitment. The ED staff treated him as a “routine boarder” awaiting an inpatient bed, with insufficiently robust behavioral monitoring. He eloped, then further complications resulted when law enforcement personnel were involved in his psychiatric emergency and when correctional mental health services were not available in a timely manner. The commentary discusses the importance of assessing for hypoxia-associated delirium and/or hippocampal damage/amnesia after any strangulation and the need for inpatient psychiatric hospitalization after emergency stabilization and management of delirium

Liliya Klimkiv, MD, Garth Utter, MD, MSc, and David K. Barnes, MD| September 27, 2023

This case describes an older adult patient with generalized abdominal pain who was eventually diagnosed with inoperable bowel necrosis. Although she appeared well and had stable vital signs, triage was delayed due to emergency department (ED) crowding, which is usually a result of hospital crowding. She was under-triaged and waited three hours before any diagnostic studies or interventions commenced. Once she was placed on a hallway gurney laboratory and imaging studies proceeded hastily. Catastrophic bowel necrosis was eventually identified, yet she was not moved to a standard ED treatment bed for another 25 minutes. Despite aggressive resuscitation, the surgeon determined that operative intervention was futile, and the patient died a short time later. The commentary highlights how hospital crowding and ED boarding can lead to delayed triage and inefficient ED throughput, which compromises patient safety and summarizes approaches to improving ED triage and throughput.

Commentary by Alyssa Bellini, MD and Edgardo S Salcedo, MD, FACS| September 27, 2023

This case highlights two “never events” involving the same patient. A first-year orthopedic surgery resident was consulted to aspirate fluid from the left ankle of a patient in the intensive care unit. The resident, accompanied by a second resident, approached the wrong patient and inserted the needle into the patient’s right ankle. At this point, a third resident entered the room and stated that it was the incorrect patient. The commentary highlights the importance of a proper time out and approaches to improve communication among all members of the care team.

Hana Camarillo, PharmD, BCACP, CDCES| September 27, 2023

A 14-year-old girl was admitted to the hospital with a new diagnosis of type 1 diabetes mellitus without ketoacidosis. Before discharge, medications intended for home use were delivered to the patient’s bedside, but the resident physician noticed a discrepancy. An insulin pen and pen needles had been ordered, but an insulin vial and extra insulin syringes were delivered. Neither the patient nor the parents had received education on how to draw up and administer insulin using a vial and syringe. The pharmacy staff reported that the insulin pen was out of stock, so the insulin vial was substituted because it contained the same active ingredient. The insulin product switch was declined, and another pharmacy was contacted to provide the insulin pen, which was delivered to the patient’s bedside the following day. The commentary summarizes the patient safety risks associated with drug shortages, drug interoperability standards, and the importance of clear communication between members of the care team if alternative therapies need to be considered

Sarah Marshall, MD and Nina M. Boe, MD| August 30, 2023

A 31-year-old pregnant patient with type 1 diabetes on an insulin pump was hospitalized for euglycemic diabetic ketoacidosis (DKA). She was treated for dehydration and vomiting, but not aggressively enough, and her metabolic acidosis worsened over several days. The primary team hesitated to prescribe medications safe in pregnancy and delayed reaching out to the Maternal Fetal Medicine (MFM) consultant, who made recommendations but did not ensure that the primary team received and understood the information. The commentary highlights how breakdowns in communication amongst providers can lead to medical errors and prolonged hospitalization and how the principles of team-based care, communication, and a culture of safety can improve care in complex health care situations.

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By Christian Bohringer, MBBS, and Ryan Osborne, MD| August 30, 2023

This case describes a 27-year-old primigravid woman who requested neuraxial anesthesia during induction of labor. The anesthesia care provider, who was sleep deprived near the end of a 48-hour call shift (during which they only slept for 3 hours), performed the procedure successfully but injected an analgesic drug that was not appropriate for this indication. As a result, the patient suffered slower onset of analgesia and significant pruritis, and required more prolonged monitoring, than if she had received the correct medication. The commentary discusses the implications of sleep deprivation, especially in high-risk settings such as anesthesia care and obstetric care, and approaches to improve patient safety during labor and delivery.