WebM&M Cases & Commentaries
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. Contribute by Submitting a Case anonymously.
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Health Care Providers
- Nurses 23
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- Patients 2
Rommel Sagana, MD, and Robert C. Hyzy, MD; March 2019
Following an elective carotid endarterectomy, an elderly woman was extubated in the operating room (OR) and brought to the recovery area. She soon developed respiratory distress necessitating urgent reintubation, which required multiple attempts. She was found to have an expanding neck hematoma, which was drained safely in the OR. Later that day after a half hour weaning trial, the respiratory therapist extubated the patient without checking for a cuff leak. Within 15 minutes, she developed acute shortness of breath and stridor, which rapidly progressed to hypoxemic respiratory failure. Urgent reintubation was difficult because her vocal cords were edematous.
Nicole M. Acquisto, PharmD, and Daniel J. Cobaugh, PharmD; March 2019
Seen in the emergency department, a man with insulin-dependent diabetes mellitus had not taken insulin for 3 days. His blood glucose levels were in the 800s with an anion-gap acidosis and positive beta hydroxybutyrate. While awaiting an ICU bed for treatment of diabetic ketoacidosis, the patient received fluids, an insulin drip was started, and blood glucose levels were monitored hourly. When lab results showed he was improving, the team decided to convert his insulin drip to subcutaneous long-acting insulin. However, both the intern and the resident ordered 50 units of insulin, and the patient received both doses—causing his blood glucose level to dip into the 30s.
Brian Clay, MD; January 2019
Following urgent catheter-directed thrombolysis to relieve acute limb ischemia caused by thrombosis of her left superficial femoral artery, an elderly woman was admitted to the ICU. While ordering a heparin drip, the resident was unaware that the EHR order set had undergone significant changes and inadvertently ordered too low a heparin dose. Although the pharmacist and bedside nurse noticed the low dose, they assumed the resident selected the dose purposefully. Because the patient was inadequately anticoagulated, she developed extensive thrombosis associated with the catheter and sheath site, requiring surgical intervention for critical limb ischemia (including amputation of the contralateral leg above the knee).
Elise Orvedal Leiten, MD, and Rune Nielsen, MD, PhD; January 2019
Hospitalized in the ICU with hypoxic respiratory failure due to community-acquired pneumonia, an elderly man had increased pulmonary secretions on hospital day 2 for which the critical care provider decided to perform bedside bronchoscopy. Following the procedure, the patient was difficult to arouse, nearly apneic, and required intubation. The care team paused and discovered that after the patient had received 2 mg of intravenous midalozam, his IV line had been flushed with an additional 10 mg of the benzodiazepine, rather than the intended normal saline. This high dose of midazolam led to the respiratory failure requiring intubation. On top of that, instead of normal saline, lidocaine had been used for the lung lavage.
- Spotlight Case
Olle ten Cate, PhD; November 2018
An ICU patient with head and spine trauma was sent for an MRI. Due his critical condition, hospital policy required a physician and nurse to accompany the patient to the MRI scanner. The ICU attending assigned a new intern, who felt unprepared to handle any crises that might arise, to transport the patient along with the nurse. While in a holding area awaiting the MRI, the patient's heart rate fell below 20 beats per minute, and the experienced ICU nurse administered atropine to recover his heart rate and blood pressure. The intern worried he had placed the patient's life at risk because of his inexperience, but he also felt uncomfortable speaking up.
Jeanna Blitz, MD; November 2018
When patients in two cases did not receive complete preanesthetic evaluation, problems with intubation ensued. In the first case, an anesthesiologist went to evaluate a morbidly obese patient scheduled for hysteroscopy. As the patient was donning her hospital gown behind a closed curtain, he waited but left without performing the preoperative assessment because the morning surgery list was overbooked and he had many other patients to see. Once in the operating room, he discovered on chart review that the woman had a history of gastroesophageal reflux. She could not be intubated, and a supraglottic airway was placed. In the second case, an elderly man with a tumor mass at the base of his tongue was scheduled for a biopsy. On examination, the anesthesiologist could not see much of the mass with the patient's mouth maximally open and tongue sticking out, and he couldn't locate the patient's head and neck CT to further evaluate the mass. The surgeon arrived late and did not communicate with the anesthesiologist about the patient. After inducing general anesthesia, laryngoscopy and intubation proved extremely difficult as the mass obscured the view of the larynx. A second anesthesiologist was called, and together they were able to intubate the patient with a fiberoptic bronchoscope.
Thomas J. Balcezak, MD, MPH, and Ohm Deshpande, MD; October 2018
An elderly man presented to the emergency department (ED) with decreased oral intake, fevers, confusion, and falling urine output. Laboratory test results revealed acute-on-chronic renal failure, and an ECG showed tall T waves, potentially a sign of severe hyperkalemia and a precursor of a dangerous arrhythmia. The ED physician initiated treatment for hyperkalemia, and the on-call intensivist and nephrologist agreed the patient needed urgent hemodialysis. Although they planned to place a hemodialysis catheter and start dialysis as soon as possible, the ICU was full and the patient was forced to "board" in the ED. On arrival to the ICU, 5 hours after the initial labs, the patient was hypotensive and unarousable. The patient went into cardiac arrest, was intubated, and received urgent treatment for hyperkalemia. The nephrologist arrived and was surprised the hemodialysis had not been started. The dialysis nurse had been told to start the dialysis after the patient arrived in the ICU but was unaware of the urgency of the situation.
Steven Plogsted, PharmD; October 2018
A 1-month-old preterm infant in the NICU receiving the standard 500 mL bag of 0.45% sodium chloride (NaCl) with heparin at low rates developed hyponatremia. Clinicians recognized the need to deliver a more concentrated sodium solution and ordered that the IV fluid be changed to a 500 mL bag of 0.9% NaCl with heparin. However, due to a natural disaster affecting the supply chain for IV fluids, 0.9% NaCl 500 mL bags were in short supply, and the order was modified to use 100 mL 0.9% NaCl bags, which were available. Since the total volume was much smaller, a lower concentration formulation of heparin was required. However, the verifying pharmacist discovered that an 10-fold higher concentration had been used to compound the fluids, and further investigation revealed this same error had occurred on five other occasions.
Jessica Katznelson, MD; September 2018
In a simulated cardiac resuscitation case of a 5-year-old boy found pulseless and apneic in the bathtub by a parent, many interprofessional teams had difficulty with resuscitation due to a lack of interoperability between the prestocked disposable laryngoscope blades and handles on the Broselow cart (a proprietary system designed to facilitate finding appropriate-sized equipment for pediatric patients requiring lifesaving interventions) with the emergency department's actual stock of blades and handles. This incompatibility led to significant delays and some failures to intubate. Teams often did not recognize the incompatibility and spent unnecessary time replacing batteries while others called for backup airway teams.
- Spotlight Case
Jeffrey Jim, MD, MPHS; August 2018
An older man with multiple medical conditions and an extensive smoking history was admitted to the hospital with worsening shortness of breath. He underwent transthoracic echocardiogram, which demonstrated severe aortic stenosis. The cardiology team recommended cardiac catheterization, but the interventional cardiologist could not advance the catheter and an aortogram revealed an abdominal aortic aneurysm (AAA) measuring 9 cm in diameter. Despite annual visits to his primary care physician, he had never undergone screening ultrasound to assess for presence of an AAA. The patient was sent emergently for surgical repair but had a complicated surgical course.
Giovanni Elia, MD; Susan Barbour, RN, MS; and Wendy G. Anderson, MD, MS; August 2018
Hospitalized in the ICU after cardiac arrest and loss of cardiac function for 15 minutes, an older man experienced worsening neurological status. After extensive discussions about goals of care, the family agreed to a DNR order. Over the next week, his condition declined, and the family decided to transition to comfort measures. Orders were written but shortly thereafter, the family spoke with the ICU resident and reversed their decision. The resident canceled the terminal extubation orders without communicating the order change to other team members. Another nurse found the canceled orders, thought it was an error, and asked another physician (who was also unaware of the change in plans) to reinstate the orders. The patient was extubated and died a few hours later.
- Spotlight Case
Resa E. Lewiss, MD; July 2018
After an emergency department (ED) physician interpreted results of a point-of-care ultrasound as showing stable low ejection fraction, some volume overload, and a mechanical mitral valve in place without regurgitation for a man with a history of congestive heart failure, end-stage renal disease, and mechanical mitral valve replacement who presented with shortness of breath, the patient was admitted with a presumed diagnosis of volume overload. Reassured by the ED physician's interpretation of the ultrasound, the hospitalist ordered no further cardiac testing. The patient underwent hemodialysis, felt better, and was discharged. Less than 12 hours later, the patient returned critically ill and in cardiogenic shock. An emergency transthoracic echocardiogram found a thrombosed mitral valve, which had led to acute mitral stenosis and cardiogenic shock.
Deborah Debono, PhD, RN, and Tracy Levett-Jones, PhD, RN; July 2018
A young adult with a progressive neurological disorder presented to an emergency department from a nursing home with a dislodged GJ tube. As a workaround to maintain patency when the GJ tube was dislodged, nursing home staff had inserted a Foley catheter into the ostomy, inflated the Foley bulb in the stomach, and tied the distal portion of the catheter in a loose knot. When the patient went to interventional radiology for new GJ tube placement, clinicians found no Foley but inserted a new GJ tube. Discharged to the nursing home, the patient was readmitted 2 days later with fever and increasing abdominal distention. An abdominal CT scan showed an obstructing foreign body in the small bowel.
Mohammad Farhad Peerally, MBChB, MRCP, and Mary Dixon-Woods, DPhil; May 2018
For a man with end-stage renal disease, a transplanted kidney was connected successfully. As the surgery was nearing completion, the surgeon instructed the anesthesiologist to give 3000 units of heparin. When preparing to close the incision, the clinicians noticed severe bleeding. The patient's blood pressure dropped, and transfusions were administered while they tried to stop the bleeding. The anesthesiologist mistakenly had administered 30,000 units of heparin. Although the surgical team administered protamine to reverse the anticoagulant effect, the bleeding and hypotension had irreversibly damaged the transplanted kidney.
Jamie M. Robertson, PhD, MPH, and Charles N. Pozner, MD; April 2018
A clinical team decided to use a radial artery approach for cardiac catheterization in a woman with morbid obesity. It took multiple attempts to access her radial artery. After catheter insertion, she experienced pain and pressure in her arm and chest. Review of the angiogram demonstrated the presence of an air embolism in the left coronary artery, introduced during the catheter insertion. Due to the difficulty of the procedure, the technician had failed to hold the syringe at the proper angle and introduced an air bubble into the patient's vessel.
- Spotlight Case
Anna Parks, MD, and Margaret C. Fang, MD, MPH ; March 2018
One day after reading only the first line of a final ultrasound result (which stated that the patient had a thrombosis), an intern reported to the ICU team that the patient had a DVT. Because she had postoperative bleeding, the team elected to place an inferior vena cava (IVC) filter rather than administer anticoagulants to prevent a pulmonary embolism (PE). The next week, a new ICU team discussed the care plan and questioned the IVC filter. The senior resident reviewed the radiology records and found the ultrasound report actually stated the thrombosis was in a superficial vein with low risk for PE, which meant that the correct step in management of this patient's thrombosis should have been surveillance.
Stephen Bacak, DO, MPH, and Loralei Thornburg, MD; March 2018
A pregnant woman presented to the emergency department 3 times in 4 days, first with symptoms of upper respiratory infection, nausea, and fever; then abdominal cramps; then shortness of breath and abdominal pain. On the third visit, she was diagnosed with influenza and possible sepsis. In between visits, the patient had been taking acetaminophen (1g every 4 hours) to control her fever. Although she had signs of acute fulminant hepatitis due to acetaminophen overdose, administration of the antidote, N-acetylcysteine, was delayed for 10 hours.
Robert E. O'Connor, MD, MPH; March 2018
Emergency medical service (EMS) providers obtained an electrocardiogram (ECG) in a woman who had developed severe chest pressure at home. The ECG revealed an ST-elevation myocardial infarction (STEMI). Unfortunately, the ECG failed to transmit to the emergency department (ED) while EMS was en route, so a "Code STEMI" was not activated. Unaware of the original ECG results, ED clinicians obtained a repeat ECG that did not demonstrate the earlier ST segment elevations, and the patient was admitted to the telemetry unit for monitoring overnight. The next morning, lab results revealed an elevated troponin level and another ECG demonstrated she had a large heart attack the previous day. Although the patient was rushed to the cardiac catheterization laboratory, the delay in treatment led to significant loss of cardiac function.
- Spotlight Case
Amy J. Starmer, MD, MPH, and Christopher P. Landrigan, MD, MPH ; February 2018
Admitted with an intracranial mass and hemorrhage, a woman with atrial fibrillation had been stable for several days when the ICU team and neurosurgeon decided that the benefits of low-dose DVT prophylaxis would outweigh the risk of serious bleeding. However, no dose or route of administration was specified, and the overnight resident ordered full-dose (rather than the prophylactic dose) anticoagulation. The hemorrhage grew and brain compression worsened, leaving the patient with no chance for meaningful recovery.
Ian Solsky, MD, and Alex B. Haynes, MD, MPH; December 2017
Prior to performing a bilateral femoral artery embolectomy on a man with coronary artery disease and diabetes, the team used a surgical safety checklist for a preoperative briefing. Although the surgeon told the anesthesiologist the patient would benefit from epidural analgesia continued into the perioperative period, he failed to mention the patient would be therapeutically anticoagulated for several days postoperatively. No postoperative debriefing was conducted. The anesthesiologist continued orders for epidural analgesia and the epidural catheter remained in place, putting the patient at risk of bleeding.