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 11
- Education and Training 2
- Logistical Approaches 5
- Policies and Operations 1
- Specialization of Care 1
- Technologic Approaches 5
- Alert fatigue 1
- Diagnostic Errors 5
- Discontinuities, Gaps, and Hand-Off Problems
- Interruptions and distractions 1
- Medication Safety 2
- Internal Medicine 8
- Nursing 1
- Spotlight Case
Eric Poon, MD, MPH; May 2018
An elderly man with a history of giant cell arteritis (GCA) presented to the rheumatology clinic with recurrent headaches one month after stopping steroids. A blood test revealed that his C-reactive protein was elevated, suggesting increased inflammation and a flare of his GCA. However, his rheumatologist was out of town and did not receive the test result. Although the covering physician saw the result, she relayed just the patient's last name without the medical record number. Because the primary rheumatologist had another patient with the same last name, GCA, and a normal CRP, follow-up with the correct patient was delayed until his next set of blood tests.
- Spotlight Case
Anna Parks, MD, and Margaret C. Fang, MD, MPH ; March 2018
One day after reading only the first line of a final ultrasound result (which stated that the patient had a thrombosis), an intern reported to the ICU team that the patient had a DVT. Because she had postoperative bleeding, the team elected to place an inferior vena cava (IVC) filter rather than administer anticoagulants to prevent a pulmonary embolism (PE). The next week, a new ICU team discussed the care plan and questioned the IVC filter. The senior resident reviewed the radiology records and found the ultrasound report actually stated the thrombosis was in a superficial vein with low risk for PE, which meant that the correct step in management of this patient's thrombosis should have been surveillance.
Robert E. O'Connor, MD, MPH; March 2018
Emergency medical service (EMS) providers obtained an electrocardiogram (ECG) in a woman who had developed severe chest pressure at home. The ECG revealed an ST-elevation myocardial infarction (STEMI). Unfortunately, the ECG failed to transmit to the emergency department (ED) while EMS was en route, so a "Code STEMI" was not activated. Unaware of the original ECG results, ED clinicians obtained a repeat ECG that did not demonstrate the earlier ST segment elevations, and the patient was admitted to the telemetry unit for monitoring overnight. The next morning, lab results revealed an elevated troponin level and another ECG demonstrated she had a large heart attack the previous day. Although the patient was rushed to the cardiac catheterization laboratory, the delay in treatment led to significant loss of cardiac function.
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.
Scott D. Nelson, PharmD, MS; March 2017
Although meningitis and neurosyphilis were ruled out for a woman presenting with a headache and blurry vision, blood tests returned indicating latent (inactive) syphilis. Due to a history of penicillin allergy, the patient was sent for testing for penicillin sensitivity, which was negative. The allergist placed orders for neurosyphilis treatment—a far higher penicillin dose than needed to treat latent syphilis, and a treatment regimen that would have required hospitalization. Upon review, the pharmacist saw that neurosyphilis had been ruled out, contacted the allergist, and the treatment plan was corrected.
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.
- 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.
Joseph S. Alpert, MD; November 2012
A woman with new onset chest pain was admitted to the hospital. Although the computer readout of her electrocardiogram stated "***ACUTE MI***" at the top, the nursing assistant who performed the test placed it in the patient's bedside chart without notifying a nurse or physician. The patient was, in fact, having a myocardial infarction, whose treatment was delayed.
- Spotlight Case
Carlton R. Moore, MD, MS; August 2012
Drawn on a Thursday, basic labs for a 10-year-old girl came back over the weekend showing a high glucose level, but neither the covering physician nor the primary pediatrician saw the results until the patient's mother called on Monday. Upon return to the clinic for follow-up, the child's glucose level was dangerously high and urinalysis showed early signs of diabetic ketoacidosis.
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.
John Q. Young, MD, MPP; July 2011
A healthy elderly man presented to his primary care doctor—a third-year internal medicine resident—for routine examination. A PSA test was markedly elevated, but the results came back after the resident had graduated, and the alert went unread. Months later, the patient presented with new onset low back pain and was diagnosed with metastatic prostate cancer.