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 6
- Culture of Safety 1
- Education and Training 2
- Error Reporting and Analysis 2
- Human Factors Engineering 5
- Quality Improvement Strategies 10
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 3
- Device-related Complications 4
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medical Complications 4
- Medication Errors/Preventable Adverse Drug Events 5
- Nonsurgical Procedural Complications
- Psychological and Social Complications 1
- Internal Medicine
- Nursing 4
- Pharmacy 1
- Spotlight Case
C. Craig Blackmore, MD, MPH; March 2019
A woman with multiple myeloma required placement of a central venous catheter for apheresis. The outpatient oncologist intended to order a nontunneled catheter via computerized provider order entry but accidentally ordered a tunneled catheter. The interventional radiologist thought the order was unusual but didn't contact the oncologist. A tunneled catheter was placed without complications. When the patient presented for apheresis, providers recognized the wrong catheter had been placed, and the patient underwent an additional procedure.
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.
Jeffrey H. Barsuk, MD, MS, and Cynthia Barnard, MBA, MSJS; December 2014
In a simulation exercise conducted in an institution that felt it was prepared for patients with actual or suspected Ebola, a man presented to the emergency department with symptoms of nausea, vomiting, and fever. He had recently returned to the US from Sierra Leone. The nurse initiated an isolation protocol and the critical care team all donned personal protective equipment. During transport, confusion about which elevators to use potentially exposed 30 staff members to Ebola. Additional issues occurred including breaching sterile technique while inserting a central line and confusion about the process to transport the patient's blood to the lab.
Delphine Tuot, MDCM, MAS; September 2014
A patient with ALS was hospitalized with presumed pneumonia and sepsis. Although he was treated with broad-spectrum antibiotics and fluid resuscitation, additional potassium was administered due to his potassium level remaining low. The patient went into cardiac arrest and resuscitation attempts were unsuccessful.
Matthias Görges, PhD, and J. Mark Ansermino, MBBCh, MSc; September 2014
A man with atrial fibrillation underwent ablation in the catheterization laboratory under general endotracheal anesthesia. The patient was extremely stable during the 7-hour procedure with vital signs hardly changing over time. Inadvertently, the noninvasive blood pressure measurement stopped recording for 1 hour but went unnoticed. After the error was discovered, the case continued without any problems and the patient was discharged home the next day as planned.
Don C. Rockey, MD; July-August 2014
Presenting with jaundice and epigastric pain, a woman with a history of multiple malignancies was admitted directly for an ultrasound-guided liver biopsy. After the procedure, the patient had low blood pressure and complained of new abdominal pain, which worsened over the next 2 hours. The bedside nurse soon found the patient unresponsive.
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.
Debora Simmons, PhD, RN; September 2011
Following surgery, a cancer patient was receiving total parenteral nutrition and lipids through a central venous catheter and pain control through an epidural catheter. A nurse mistakenly connected a new bottle of lipids to the epidural tubing rather than the central line, and the error was not noticed for several hours.
- Spotlight Case
Jean L. Holley, MD ; October 2010
A man with end-stage renal disease on hemodialysis was dialyzed with equipment that had been inappropriately reused, exposing the patient to another patient's blood numerous times.
Dorrie K. Fontaine, RN, PhD; October 2009
A toddler admitted for severe dehydration requires a femoral IV. The anesthesiologist ignores a nurse's reminder that hospital policy requires monitoring if a child is to receive sedation in the unit. When the nurse attempts to stop the procedure, the anesthesiologist throws the needle to the floor.
Lisa Schulmeister, RN, MN, APRN-BC; January 2008
A nurse has trouble placing an IV catheter for a woman receiving her first dose of outpatient chemotherapy. The patient complains of pain at the site. Closer examination revealed that the chemotherapy had infused outside of the vein into the skin.
Richard Cohan, MD; September 2004
Prior to a CT scan, a patient states that he is not allergic to x-ray dye. Soon after injection, he goes into anaphylactic shock.
Mark V. Williams, MD; July 2004
A man sent for a Holter monitor inadvertently arrives at the allergy clinic and receives a skin test instead.
- Spotlight Case
Thomas H. Gallagher, MD; Wendy Levinson, MD; June 2004
A child is mistakenly vaccinated for hepatitis A, rather than B. Despite forthright disclosure and no evident harm to the child, the father becomes incredibly angry at the providers.
Timothy S. Lesar, PharmD; November 2003
An unclear verbal order leads to administration of the wrong drug.
- Spotlight Case
Adrienne G. Randolph, MD, MSc ; May 2003
An infant codes due to pulmonary emboli after a central line flush.