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.
Narrow Results Clear All
- Communication Improvement 8
- Culture of Safety 2
- Education and Training 4
- Error Reporting and Analysis 5
- Human Factors Engineering 10
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Quality Improvement Strategies 5
- Specialization of Care 1
- Teamwork 5
- Technologic Approaches 4
- Device-related Complications 3
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 3
- Medical Complications 3
- Medication Safety 1
- Psychological and Social Complications 1
- Surgical Complications
Jeanna Blitz, MD; November 2018
When patients in two cases did not receive complete preanesthetic evaluation, problems with intubation ensued. In the first case, an anesthesiologist went to evaluate a morbidly obese patient scheduled for hysteroscopy. As the patient was donning her hospital gown behind a closed curtain, he waited but left without performing the preoperative assessment because the morning surgery list was overbooked and he had many other patients to see. Once in the operating room, he discovered on chart review that the woman had a history of gastroesophageal reflux. She could not be intubated, and a supraglottic airway was placed. In the second case, an elderly man with a tumor mass at the base of his tongue was scheduled for a biopsy. On examination, the anesthesiologist could not see much of the mass with the patient's mouth maximally open and tongue sticking out, and he couldn't locate the patient's head and neck CT to further evaluate the mass. The surgeon arrived late and did not communicate with the anesthesiologist about the patient. After inducing general anesthesia, laryngoscopy and intubation proved extremely difficult as the mass obscured the view of the larynx. A second anesthesiologist was called, and together they were able to intubate the patient with a fiberoptic bronchoscope.
Krishna Moorthy, MD, MS; January 2015
Following outpatient laparoscopic surgery to repair an inguinal hernia, a man with no significant past medical history had high levels of pain at the surgical site and was admitted to the hospital. With sustained pain on postoperative day 3, the patient developed tachycardia with abdominal distension and a low-grade fever. A CT scan revealed a bowel perforation, which required surgery and a lengthy ICU stay due to septicemia.
John H. Eichhorn, MD; January 2015
While undergoing an elective coronary artery bypass graft (CABG) and ablation, an elderly man had a pulmonary artery catheter (PAC) placed to monitor his hemodynamic status. During the operation, the team was informed that another patient needed an emergency CABG. In the rush to attend to the second patient, the PAC in the first was left inflated for a prolonged period, which could have led to a catastrophic complication.
Robert R. Cima, MD, MA; September 2012
Following successful bypass surgery and mitral valve repair, an elderly man with diabetes, hypertension, and end-stage renal disease continued to attend hemodialysis and other clinic visits regularly. Eight months later, he was admitted to the hospital with shaking chills, confusion, and a collection of pus in his chest. A surgical procedure to free the trapped lung also uncovered a surgical instrument from the previous surgery.
Christopher R. Lee, MD; October 2009
Following surgery for peripheral vascular disease, a patient otherwise ready for discharge complains of liquid shooting from his nose. The surgeons make the patient NPO and order a consultation from an otolaryngologist, who discovers the nasopharyngeal airway still lodged in the patient's nasal cavity.
Richard A. Smith, DDS; July-August 2007
A patient underwent tooth extraction, but awoke from anesthesia and found that the wrong two teeth had been removed.
- Spotlight Case
Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD, MPP, MPH; May 2006
A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.
Todd Sagin, MD, JD; March 2006
Despite formal investigation of complications in past cases, a senior surgeon is still allowed to operate on a patient, with disastrous results.
Dennis S. O'Leary, MD; William E. Jacott, MD; December 2004
Despite a "time out" and having his leg marked by the surgeon, a patient comes perilously close to having surgery on the wrong leg.
Kay Ball, RN, MSA ; October 2004
While repositioning the trocar, a surgeon places the laparoscope on a tray sitting on the patient. When she picks it back up, she notices that the drape has melted and the patient has a second-degree burn.
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.
J. Forrest Calland, MD; January 2004
During a hernia repair, surgeons decide to remove a patient's hydrocele, spermatic cord, and left testiclewithout realizing that his right testicle had been removed previously.
- Spotlight Case
Eric J. Thomas, MD, MPH; Frederick A. Moore, MD; November 2003
A scrub nurse cannot find a missing suction catheter tip, but the surgeon closes the patient. A post-operative x-ray reveals the tip in the patient's chest.
- Spotlight Case
Charles Vincent, PhD; October 2003
Trusting his memory more than the chart, a surgeon directs a resident to remove the wrong side on a patient with unilateral vulvar cancer.
Verna C. Gibbs, MD; September 2003
A patient dies from infection and complications months after surgery; a retained sponge is found at autopsy.
Andre R. Campbell, MD; April 2003
Laparoscopic colostomy completed in reverse induces total bowel obstruction.
- Spotlight Case
Paul Barach, MD, MPH; February 2003
A boy undergoing knee surgery stopped breathing after inadvertently being given a paralytic medication instead of an antibiotic.
Verna C. Gibbs, MD; Lucian L. Leape, MD ; February 2003
A woman required emergency vascular surgery due to a complication during routine laparoscopic tubal ligation.