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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- Spotlight Case
by Kristin E. Sandau, PhD, RN, and Marjorie Funk, PhD, RN; April 2019
An elderly woman with a history of dementia, chronic obstructive pulmonary disease, hypertension, and congestive heart failure (CHF) was brought to the emergency department and found to meet criteria for sepsis. Due to her CHF, she was admitted to a unit with telemetry monitoring, which at this institution was performed remotely. When the nurse came to check the patient's vital signs several hours later, she found the patient to be unresponsive and apneic, with no palpable pulse. A Code Blue was called, but the patient died. Although the telemetry technician had recognized progressive bradycardia and called the hospital floor several minutes before the code, he was placed on hold because the nurse was busy with another patient. While he was holding, he observed worsening bradycardia, eventually transitioning to asystole, and tried to redial the unit, but no one answered.
Neal L. Benowitz, MD; April 2019
A woman who required oxygen at home via nasal cannula and used a continuous positive airway pressure (CPAP) machine at night was admitted for an exacerbation of chronic obstructive pulmonary disease without any signs of infection. During her hospital stay, she continued to require 5 liters of oxygen by nasal cannula. Although the patient had received smoking cessation education and no longer smoked regular cigarettes, she did continue to vape with an electronic cigarette (e-cigarette). Having not been told to avoid vaping in the hospital, the patient took a puff on her e-cigarette while she was receiving oxygen through her nasal cannula and sparked an explosion. She ripped off the nasal cannula, which had melted, and sustained burns to her face and hand, resulting in a prolonged hospitalization for burn care and extensive pain management.
Stephanie Rogers, MD, and Derek Ward, MD; April 2019
An elderly man with a complicated medical history slipped on a rug at home, fell, and injured his hip. Emergency department evaluation and imaging revealed no head injury and a left intertrochanteric hip fracture. Although he was admitted to the orthopedic surgery service, with surgery to fix the fracture initially scheduled for the next day, the operation was delayed by 3 days due to several emergent trauma cases and lack of surgeon availability. He ultimately underwent surgery and was discharged a few days later but was readmitted several weeks later with chest pain and shortness of breath. He was found to have a pulmonary embolism; anticoagulation was initiated. The patient's rehabilitation was delayed, his recovery was prolonged, and he never returned to his baseline functional status.
- Spotlight Case
Stephanie Mueller, MD, MPH; February 2019
To transfer a man with possible sepsis to a hospital with subspecialty and critical care, a physician was unaware of a formal protocol and called a colleague at the academic medical center. The colleague secured a bed, and the patient was sent over. However, neither clinical data nor the details of the patient's current condition were transmitted to the hospital's transfer center, and the receiving physician booked a general ward bed rather than an ICU bed. When the patient arrived, his mentation was altered and breathing was rapid. The nurse called the rapid response team, but the patient went into cardiac arrest.
Lina Bergman, RN, MSc, and Wendy Chaboyer, RN, PhD; February 2019
Following surgery under general anesthesia, a boy was extubated and brought to postanesthesia care unit (PACU). Due to the patient's age and length of the surgery, the PACU anesthesiologist ordered continuous pulse-oximetry monitoring for 24 hours. Deemed stable to leave the PACU, the boy was transported to the regular floor. When the nurse went to place the patient on pulse oximetry, she realized he was markedly hypoxic. She administered oxygen by face mask, but he became bradycardic and hypotensive and a code blue was called.
Robert Chang, MD, and Scott Flanders, MD; February 2019
A woman was admitted to a hospital's telemetry floor for management of uncontrolled hypertension and palpitations. On the first hospital day, she complained of right arm numbness and weakness and had new difficulty answering questions. The nurse called the hospitalist and relayed the arm symptoms, but not the word-finding difficulty. The hospitalist asked the nurse to call for a neurology consultation. Four hours later, the patient's weakness had progressed; she was now completely unable to move her right arm. At that point, neither the hospitalist nor the neurology consultant had evaluated the patient in person. A stat head CT revealed a large ischemic stroke.
- Spotlight Case
Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD; January 2019
A woman with a history of psychiatric illness presented to the emergency department with agitation, hallucinations, tachycardia, and transient hypoxia. The consulting psychiatric resident attributed the tachycardia and hypoxia to her underlying agitation and admitted her to an inpatient psychiatric facility. Over the next few days, her tachycardia persisted and continued to be attributed to her psychiatric disease. On hospital day 5, the patient was found unresponsive and febrile, with worsening tachycardia, tachypnea, and hypoxia; she had diffuse myoclonus and increased muscle tone. She was transferred to the ICU of the hospital, where a chest CT scan revealed bilateral pulmonary emboli (explaining the tachycardia and hypoxia), and clinicians also diagnosed neuroleptic malignant syndrome (a rare and life-threatening reaction to some psychiatric medications).
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.
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.
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.
Brian F. Olkowski, DPT; Mary Ravenel, MSN; and Michael F. Stiefel, MD, PhD; April 2018
Following elective lumbar drain placement to treat hydrocephalus and elevated intracranial pressures, a woman was admitted to the ICU for monitoring. After the patient participated in prescribed physical therapy on day 5, she complained of headaches, decreased appetite, and worsening visual problems—similar to her symptoms on admission. The nurse attributed the complaints to depression and took no action. Early in the morning, the patient was found barely arousable. The lumbar drain had dislodged, and a CT scan revealed the return of extensive hydrocephalus.
- Spotlight Case
Craig A. Umscheid, MD, MSCE; John D. McGreevey, III, MD; and S. Ryan Greysen, MD, MHS, MA; December 2017
Found unconscious at home, an older woman with advanced dementia and end-stage renal disease was resuscitated in the field and taken to the emergency department, where she was registered with a temporary medical record number. Once her actual medical record was identified, her DNR/DNI status was identified. After recognizing this and having discussions with the family, she was transitioned to comfort care and died a few hours later. Two months later, the clinic called the patient's home with an appointment reminder. The primary care physician had not been contacted about the patient's hospitalization and the electronic record system had not listed the patient as deceased.
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.
- Spotlight Case
Anne M. Turner, MD, MLIS, MPH; October 2017
A Spanish-speaking woman presented to an urgent care clinic complaining of headache and worsening dizziness, for which the treating clinician ordered an MRI. When the results came in with no concerning findings later that day, the provider used Google Translate to write a letter informing the patient of the results. The patient interpreted the letter to mean that the results were concerning. This miscommunication led to patient distress and extra visits to both urgent care and the emergency department.
Nancy Staggers, PhD, RN; October 2017
Hospitalized with sepsis secondary to an infected IV line through which she was receiving treprostnil (a high-alert medication used to treat pulmonary hypertension), a woman was transferred to interventional radiology for placement of a new permanent catheter once the infection cleared. Sign-off between departments included a warning not to flush the line since it would lead to a dangerous overdose. However, while attempting to identify an infusion pump alarm, a radiology technician accidentally flushed the line, which led to a near code situation.
Vinod K. Bhutani, MD, and Ronald J. Wong; October 2017
A newborn with elevated total serum bilirubin (TSB) due to hemolytic disease was placed on a mattress with embedded phototherapy lights for treatment, but the TSB continued to climb. The patient was transferred to the neonatal ICU for an exchange transfusion. The neonatologist requested testing of the phototherapy lights, and their irradiance level was found to be well below the recommended level. The lights were replaced, the patient's TSB level began to drop, and the exchange transfusion was aborted.
Jennifer Morris and Marie Bismark, MD; September 2016
Assuming its dosing was similar to morphine, a physician ordered 4 mg of IV hydromorphone for a hospitalized woman with pain from acute pancreatitis. As 1 mg of IV hydromorphone is equivalent to 4 mg of morphine, this represented a large overdose. The patient was soon found unresponsive and apneic—requiring ICU admission, a naloxone infusion overnight, and intubation. While investigating the error, the hospital found other complaints against that particular physician.
Michael E. Detsky, MD, MSc; April 2016
During a hospitalization after a cardiac arrest, an older man underwent placement of a PEG tube for nutrition, and an abdominal radiograph the next day showed "free air under the diaphragm." Although the resident got a "curbside consult" from surgery saying this finding should be monitored, the consult was not documented in the chart. Two days later, the patient was urgently taken to surgery to repair a large gastric perforation and spillage of tube feeds into the peritoneum and then transferred to the ICU in septic shock.
Jeanne M. Farnan, MD, MHPE; April 2016
A man with a pulmonary embolus was ordered argatroban for anticoagulation. The next day, an intern noticed that the patient in the next room, a woman with a GI bleed, had argatroban hanging on her IV pole, but the label showed the name of the man with the pulmonary embolus. The nurse was notified, the medication was stopped, and the error was disclosed to the patient.