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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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.
James Stotts, RN, MS, CNS, and Audrey Lyndon, PhD, RNC; May 2014
In the preoperative area, a man scheduled for excision of a groin lipoma received regional anesthesia (right iliac block) and was taken to the operating room. There, without alerting anyone, the patient attempted to rise to use the restroom, but—because his leg was numb—fell and hit his head. He reported acute neck pain and was transferred to the local emergency department.
Matt M. Kurrek, MD, and Rebecca S. Twersky, MD, MPH; August 2012
Following spinal anesthesia for an outpatient procedure, a patient is discharged and instructed to take sitz baths with tepid water. The patient misunderstood the instructions, using scalding water instead, and residual anesthesia blunted his response to the hot water.
John Starling III, MD; March 2012
Following biopsies for two skin lesions on his left cheek, a patient was sent to an outside surgeon for excision of squamous cell carcinoma. Although the referral included a description and diagram, the wrong lesion was removed.
Kevin C. Huoh, MD; Kristina W. Rosbe, MD; June 2011
A healthy child underwent tonsillectomy and adenoidectomy. Extubated after an uneventful surgery, within an hour the child became hypoxic and unable to breathe spontaneously, requiring reintubation.
Jose L. Baez-Escudero, MD; Glenn N. Levine, MD; September 2007
A man underwent coronary angiography; one stent was placed and bypass surgery was scheduled for 4 days later. He developed bleeding at the catheter site and returned to the hospital. A CT scan revealed a large retroperitoneal hematoma, which was repaired surgically. While in the hospital awaiting the delayed bypass surgery, the patient had a cardiac arrest and died.
James A. Yates, MD; March 2006
A man undergoes plastic surgery at an outpatient center and winds up with a complication requiring prolonged stay in the ICU.
Marilynn M. Rosenthal, PhD; July 2003
An anxious patient awaiting ambulatory surgery is mistakenly put on the wrong operating table.