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 Improvement 4
- Culture of Safety 1
- Education and Training 2
- Error Reporting and Analysis 1
- Human Factors Engineering 4
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Quality Improvement Strategies 8
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 2
- Device-related Complications 1
- Diagnostic Errors 6
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 1
- Interruptions and distractions 1
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 1
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 1
- Surgical Complications 2
- Nursing 1
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.
- Spotlight Case
Alex A. Balekian, MD, MSHS, and Michael K. Gould, MD, MS; December 2012
At his first visit with a new physician, a man with a "spot" on his lung reported being followed with CT scans every 6–12 months for 8 years. In total, the patient had more than 20 CT scans.
Jeffrey M. Rohde, MD, and Scott A. Flanders, MD; November 2012
A 32-year-old man went to the emergency department with fever and pleuritic chest pain. Following an extensive work-up, he was discharged with "fever, pleural effusion, and chest wall pain", but no clear diagnosis. He returned to the ED 3 days later with worsening pain, continued fever, a new cough, and dyspnea. The patient was started on antibiotics and admitted for pneumonia with effusion.
Elinore F. McCance-Katz, MD, PhD; October 2012
A man with a long history of opioid dependence (and smoking) went to a substance abuse program for detoxification. The patient received buprenorphine/naloxone and was found unresponsive and cyanotic a few hours later. He was diagnosed with opiate-induced respiratory distress complicated by pneumonia and chronic obstructive pulmonary disease.
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.
Rainu Kaushal, MD, MPH; Erika Abramson, MD ; August 2009
The theophylline dose of a patient admitted for COPD exacerbation and pneumonia is doubled, and he develops atrial flutter with a rapid ventricular response, chest pain, and increased shortness of breath.
Ross Koppel, PhD; April 2009
A patient hospitalized with Pneumocystis jiroveci pneumonia and advanced AIDS is given another patient's malignant biopsy results, leading his primary physician to mistakenly recommend hospice care.
- Spotlight Case
Christopher Fee, MD; February-March 2009
Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.
- Spotlight Case
David M. Gaba, MD ; October 2004
A dyspneic patient fails to improve after being placed on high-flow oxygen. The respiratory therapist soon discovers why: the patient is mistakenly receiving compressed room air.
J. Mark FitzGerald, MB; Dick Menzies, MD; May 2004
A woman hospitalized for 3 weeks with a respiratory infection was not responding to broad-spectrum antibiotics. Tragically, she died a few days before test results revealed that she actually had tuberculosis.
Marc J. Shapiro, MD; February 2004
Trusting an incorrectly labeled chest x-ray over physical exam findings, a resident places a chest tube for pneumothorax in the wrong side.
John E. Heffner, MD ; May 2003
A chest x-ray incorrectly read as pleural effusion, rather than lung collapse, leads to iatrogenic pneumothorax following thoracentesis.
- Spotlight Case
Adrienne G. Randolph, MD, MSc ; May 2003
An infant codes due to pulmonary emboli after a central line flush.