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
- Quality Improvement Strategies 1
- Technologic Approaches 2
- Device-related Complications 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 3
- Medication Safety 2
Cristiane Gomes-Lima, MD, and Kenneth D. Burman, MD; November 2017
Two cases in which thyroid function tests were ordered appropriately but not acted upon in a timely fashion illustrate the challenges of thyroid emergencies. The patient in Case #1 had a history of hyperthyroidism and noted not taking his medications for months, yet no one addressed his abnormal thyroid function tests until hospital day 3. He had thyroid storm. In Case #2, providers neglected to follow up on the patient's abnormal thyroid function tests, even though she was taking a medication with a known risk of thyroid toxicity. She had myxedema coma.
- Spotlight Case
Patricia Juang, MD, and Kristen Kulasa, MD; April 2016
While hospitalized, a man with diabetes had difficult-to-control blood sugars, with multiple episodes of both critical hypoglycemia and serious hyperglycemia. Because "holds" of the patient's insulin were not clearly documented in the electronic health record and blood sugar readings were not uploaded in real time, providers were unaware of how much insulin had actually been given.
Tosha Wetterneck, MD, MS; December 2015
Hospitalized with nonketotic hyperglycemia, a man was placed on IV insulin and his blood sugars improved. That evening, the patient was transferred to the ICU with chest pain and his IV insulin order was changed to sliding scale subcutaneous insulin. However, over the next several hours, the patient again developed hyperglycemia.
- Spotlight Case
Gail B. Slap, MD, MSc; February 2010
An overweight teenaged girl came to the pediatrics clinic for routine follow-up of her type 2 diabetes, complaining of nonspecific, intermittent abdominal pain and worsening acne. The physician prescribed topical acne cream and increased her diabetes medications. The next day, an obstetrician notified the pediatrician that this patient had delivered a healthy infant via Caesarian section overnight.
Curtiss B. Cook, MD; January 2009
Admitted to the hospital for surgery, a man with type 1 diabetes mellitus asked the staff to leave his home insulin pump in place but did not mention that he was adjusting his insulin pump himself based on serial glucose measurements. As the patient was also receiving an intravenous insulin infusion, he developed hypoglycemia.