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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- Communication between Providers 22
- Culture of Safety 2
- Education and Training 8
- Error Reporting and Analysis 4
- Human Factors Engineering 7
- Legal and Policy Approaches 6
- Logistical Approaches 2
- Quality Improvement Strategies 15
- Specialization of Care 2
- Teamwork 1
- Technologic Approaches 10
- Device-related Complications 5
- Diagnostic Errors 20
- Discontinuities, Gaps, and Hand-Off Problems 19
- Interruptions and distractions 1
- Medical Complications 4
- Medication Errors/Preventable Adverse Drug Events 9
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 3
- Surgical Complications 1
- Cardiology 10
- Internal Medicine
- Nursing 3
- Pharmacy 1
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.
- 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.
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.
Casey A. Cable, MD; David J. Murphy, MD, PhD; and Greg S. Martin, MD, MSc; September 2017
For an older patient presenting with upper back pain and faint bilateral crackles, physicians misinterpreted a negative sepsis screen as a negative infection screen and delayed antibiotic treatment for pneumonia. The patient developed worsened hypoxemia, hypotension, delirium, and progressive organ failure.
Jeffrey J. Mucksavage, PharmD, and Eljim P. Tesoro, PharmD; January 2017
An emergency department physician ordered a loading dose of IV phenytoin for a woman with a history of seizures and cardiac arrest. However, he failed to order that the loading dose be switched back to an appropriate (and lower) maintenance dose, and 3 days later the patient developed somnolence, severe ataxia, and dysarthria. Her serum phenytoin level was 3 times the maximum therapeutic level.
Osama Loubani, MD; January 2017
A man with a history of cardiac disease was brought to the emergency department for septic shock of possible intra-abdominal origin. A vasopressor was ordered. However, rather than delivering it through a central line, the norepinephrine was infused through a peripheral line. The medication extravasated into the subcutaneous tissue of the patient's arm. Despite attempts to salvage the patient's wrist and fingers, three of his fingertips had to be amputated.
Mitchell Levy, MD; October 2016
Administered antibiotics in the emergency department and rushed to the operating room for emergent cesarean delivery, a pregnant woman was found to have an infection of the amniotic sac. After delivery, she was transferred to the hospital floor without a continuation order for antibiotics. Within 24 hours, the inpatient team realized she had developed septic shock.
Cindy S. Lee, MD, and Christopher P. Hess, MD, PhD; May 2016
An older man with a history of heavy smoking and chest pain underwent a chest CT in the emergency department that showed no evidence of an aortic dissection on the preliminary read. Although the patient followed up soon thereafter with a new primary care physician, it was not discovered until several months later that a suspicious lung nodule had been spotted on the initial CT.
Kevin Moore, MBBS, PhD; December 2015
A man with cirrhosis and abdominal distension was found to have significant ascites. The emergency department providers performed a large volume paracentesis to relieve his symptoms, but, as the 10th liter of fluid was removed, the patient became acutely hypotensive.
Frank I. Scott, MD, MSCE, and Gary R. Lichtenstein, MD; June 2015
Admitted to the hospital with a small bowel obstruction and ileitis consistent with an exacerbation of Crohn disease, a man was given empiric antibiotic therapy and infliximab prior to consultation with gastroenterology. Gastroenterology recommended sending stool studies and initiating infliximab only after those studies were negative for infection. The stool studies were sent, but the primary team did not discontinue the infliximab. The patient was found to have Clostridium difficile infection.
- Spotlight Case
David Shimabukuro, MD; May 2015
An older woman with a history of pulmonary hypertension, chronic obstructive pulmonary disease, and coronary artery disease was admitted to the hospital with pneumonia. She received levofloxacin (administered approximately 3 hours after presentation). Twenty-four hours after admission, her blood cultures grew methicillin-resistant Staphylococcus aureus, and vancomycin was added to her antibiotic regimen. The patient developed respiratory failure requiring mechanical ventilation as well as septic shock requiring vasopressors.
Dustin W. Ballard, MD, MBE; David R. Vinson, MD; and Dustin G. Mark, MD; May 2015
A man with a history of poorly controlled diabetes and pancreatic insufficiency was found unresponsive. Paramedics transported him to the emergency department, where a resident placed a right internal jugular line for access but was unable to confirm placement. The resident pulled the line, opened a second line insertion kit, started over, and confirmed placement with ultrasound. The patient went into cardiac arrest, and a chest radiograph noted a retained guidewire in the pulmonary artery.
- Spotlight Case
Shirley Beng Suat Ooi, MBBS (S'pore); April 2015
A woman admitted to the hospital with a presumed transient ischemic attack and possible gastrointestinal bleeding was found unconscious and in cardiac arrest on hospital day 2. Despite maximal resuscitation efforts, the patient died. Autopsy revealed that the cause of death was an acute aortic dissection.
- Spotlight Case
Terence Goh, MBBS, and Lee Gan Goh, MBBS; July-August 2014
Admitted with bruising from a fall and persistent pain on his left side, a patient was kept in the emergency department overnight due to crowding. After being reevaluated by the surgical service the next day, the patient was urgently taken to the operating room for probable necrotizing fasciitis and pyomysitis.
- Spotlight Case
William Martinez, MD, MS, and Gerald B. Hickson, MD; March 2014
Hospitalized 3 times within 2 months presumably for sepsis, a woman with diabetes on metformin presented to the emergency department with the same set of symptoms as her previous admissions. After reviewing her records, the admitting team determined that the patient's presentation for this and earlier admissions was more consistent with acute lactic acidosis secondary to metformin than sepsis.
Anthony P. Weiss, MD, MBA, and Jerrold F. Rosenbaum, MD; April 2013
A young man with a history of Crohn disease and severe mental illness was admitted with acute pancreatitis. The medical team decided to discontinue olanzapine, an antipsychotic medication that can cause pancreatitis, without consulting the patient's psychiatrist. The outcome was fatal.
Mark Ault, MD, and Bradley Rosen, MD, MBA; February 2013
A woman found unresponsive at home presented to the ED via ambulance. The cardiology team used the central line placed during resuscitation to deliver medications and fluids during pacemaker insertion. Hours later, a chest radiograph showed whiteout of the right lung, and clinicians realized that the tip of the line was actually within the lung.
Steven K. Polevoi, MD; December 2012
Following an emergency department (ED) evaluation for chest pain, a patient was discharged with a presumptive diagnosis of gastroesophageal reflux disease. Two days later, he returned to the ED in severe distress, now with an acute myocardial infarction and a large pericardial effusion.
Nancy Moureau, BSN, RN, CRNI, CPUI, VA-BC; December 2012
A woman undergoing treatment for myasthenia gravis via PICC developed extensive catheter-related thrombosis, bacteremia, and sepsis, and ultimately died. Although the PICC line was placed at one facility, the patient was receiving treatment at another, raising questions about who had responsibility for the line.