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 13
- Culture of Safety 1
- Education and Training 2
- Error Reporting and Analysis 3
- Human Factors Engineering 1
- Legal and Policy Approaches 2
- Logistical Approaches 6
- Policies and Operations 1
- Quality Improvement Strategies 5
- Specialization of Care 1
- Technologic Approaches 5
- Diagnostic Errors 9
- Discontinuities, Gaps, and Hand-Off Problems 11
- Identification Errors 3
- Medication Safety 1
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 4
- Transfusion Complications 1
- Nursing 1
Christopher Moriates, MD; January 2018
Following a positive fecal immunochemical test (a screening test for colon cancer), a colonoscopy was ordered for a 50-year-old man. Two months later, the nurse called him to see if he had obtained the colonoscopy. The patient reported that he was unable to schedule it due to cost of the copayment. The primary physician called the insurance company and was informed that the colonoscopy would be covered in full if the indication was written as preventive rather than diagnostic. Ultimately, the patient received the colonoscopy and was diagnosed with colon cancer 6 months after his initial positive screening test.
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.
Yael K. Heher, MD, MPH; November 2017
A resident entered orders into the EHR for a biopsy specimen of a patient's rash to be sent to pathology for evaluation. The biopsy specimen was delivered to the laboratory without a copy of the orders. Because pathology and the medicine service did not share the same EHR, the laboratory could neither view the orders nor direct the biopsy to the appropriate area for analysis without a printed copy. The next day, the resident attempted to look up the results but found none.
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.
Sarah Doernberg, MD, MAS; July 2017
A woman was discharged with instructions to complete an antibiotic course for C. difficile. The same day, the microbiology laboratory notified the patient's nurse that her blood culture grew Listeria monocytogenes, a bacterium that can cause life-threatening infection. However, the result was not communicated to the medical team prior to discharge.
Christopher M. Lehman, MD; May 2017
In the emergency department, an older man with multiple medical conditions was found to have evidence of acute kidney injury and an elevated serum potassium level. However, the blood sample was hemolyzed, which can alter the reading. Although the patient was admitted and a repeat potassium level was ordered, the physician did not institute treatment for hyperkalemia. Almost immediately after the laboratory called with a panic result indicating a dangerously high potassium level, the patient went into cardiac arrest.
Gerald J. Kost, MD, PhD, MS, and Sharon Ehrmeyer, PhD; February 2017
In an outpatient clinic, the nurse entered results of all daily point-of-care tests into the electronic health record at the end of her shift. She mistakenly entered one patient's urine pregnancy test result as positive instead of negative. When the patient's provider received electronic notification of the result, she recognized the error and corrected the medical record.
- Spotlight Case
Eliot L. Siegel, MD; January 2017
Following a hysterectomy, a woman was discharged but then readmitted for pelvic pain. The radiologist reported a large pelvic abscess on the repeat CT scan, and the gynecologist took the patient to the operating room for treatment based on the report alone, without viewing the images herself. In the OR, the gynecologist could not locate the abscess and stopped the surgery to look at the CT images. She realized that what the radiologist had read as an abscess was the patient's normal ovary.
Jonathan R. Genzen, MD, PhD, and Heather N. Signorelli, DO; March 2015
After presenting to the emergency department, a woman with chest pain was given nitroglycerine and a so-called GI cocktail. Her electrocardiogram was unremarkable, and she was scheduled for a stress test the next morning. A few minutes into the stress test, the patient collapsed and went into cardiac arrest.
Thomas B. Newman, MD, MPH, and M. Jeffrey Maisels, MB, BCh, DSc; March 2014
Following delivery and successful phototherapy for hyperbilirubinemia, an infant developed anemia over the next few weeks. Found to have Rh hemolytic disease, the infant was admitted to the hospital for blood transfusion and close monitoring.
Reza Alaghehbandan, MD, MSc, and Stephen S. Raab, MD; March 2013
A woman with abdominal pain, bloating, and weight loss went to her primary physician, who ordered imaging and a biopsy. Lymph node pathology was reported as Castleman disease. A specialist felt the presentation and test results were atypical for this diagnosis. Further testing revealed adult-onset celiac disease.
- Spotlight Case
David Shapiro, MD, JD; February 2013
After her discharge, providers were unable to reach a young woman hospitalized for heavy vaginal bleeding, whose chlamydia culture returned positive. The delay in treatment led to infection of her fallopian tubes and required hospitalization for intravenous antibiotics.
Vanitha Janakiraman Mohta, MD; February 2012
A pregnant woman with new onset hypertension and proteinuria was admitted to the hospital for further testing. Test results for a 24-hour urine collection were initially reported as normal in the electronic medical record, and discharge planning was begun. However, a later amended report showed the results were elevated and abnormal, confirming a diagnosis of preeclampsia.
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.
Melvin P. Weinstein, MD; January 2008
Blood culture results on a man with chronic health problems revealed Corynebacterium spp. One month later, the patient became ill, and cultures again revealed Corynebacterium. The physician who received the result was unfamiliar with the patient, assumed that this finding was a contaminant, and took no action. Three weeks later, the patient was admitted and diagnosed with subacute bacterial endocarditis.
Conrad V. Fernandez, MD; June 2007
A healthy woman who volunteered to participate in a radiology study was notified several weeks later of a "major abnormality" discovered on her MRI. She sought further evaluation and was diagnosed with uterine cancer.
Michael Astion, MD, PhD ; December 2006
A man admitted to the hospital for elective surgery has blood drawn. Despite a policy for proper identification, the blood samples were all mislabeled with another patient's name. The error was discovered at the lab, and there was no harm to the patient.
Neil A. Holtzman, MD, MPH; December 2004
A pregnant woman is offered genetic testing for herself and her husband. Although he declines, the next time he undergoes routine testing, the phlebotomist overrides the consent in the computerized record and runs the test anyway.
Michael Astion, MD, PhD; June 2004
Just before leaving for the weekend, a physician orders a test for a communicable infection. Although the result arrives and isolation signs are placed on the patient's door, none of the covering physicians are notified, and the float nurses mistakenly assume the patient is already receiving treatment.
Bryan A. Liang, MD, PhD, JD; May 2004
Understanding that she may lose her life without it, a woman severely injured in a collision rejects a blood transfusion for religious reasons. However, her parents persuade the physicians otherwise, and the woman lives.