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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- Spotlight Case
Stephanie Mueller, MD, MPH; February 2019
To transfer a man with possible sepsis to a hospital with subspecialty and critical care, a physician was unaware of a formal protocol and called a colleague at the academic medical center. The colleague secured a bed, and the patient was sent over. However, neither clinical data nor the details of the patient's current condition were transmitted to the hospital's transfer center, and the receiving physician booked a general ward bed rather than an ICU bed. When the patient arrived, his mentation was altered and breathing was rapid. The nurse called the rapid response team, but the patient went into cardiac arrest.
Lina Bergman, RN, MSc, and Wendy Chaboyer, RN, PhD; February 2019
Following surgery under general anesthesia, a boy was extubated and brought to postanesthesia care unit (PACU). Due to the patient's age and length of the surgery, the PACU anesthesiologist ordered continuous pulse-oximetry monitoring for 24 hours. Deemed stable to leave the PACU, the boy was transported to the regular floor. When the nurse went to place the patient on pulse oximetry, she realized he was markedly hypoxic. She administered oxygen by face mask, but he became bradycardic and hypotensive and a code blue was called.
Robert Chang, MD, and Scott Flanders, MD; February 2019
A woman was admitted to a hospital's telemetry floor for management of uncontrolled hypertension and palpitations. On the first hospital day, she complained of right arm numbness and weakness and had new difficulty answering questions. The nurse called the hospitalist and relayed the arm symptoms, but not the word-finding difficulty. The hospitalist asked the nurse to call for a neurology consultation. Four hours later, the patient's weakness had progressed; she was now completely unable to move her right arm. At that point, neither the hospitalist nor the neurology consultant had evaluated the patient in person. A stat head CT revealed a large ischemic stroke.
- Spotlight Case
Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD; January 2019
A woman with a history of psychiatric illness presented to the emergency department with agitation, hallucinations, tachycardia, and transient hypoxia. The consulting psychiatric resident attributed the tachycardia and hypoxia to her underlying agitation and admitted her to an inpatient psychiatric facility. Over the next few days, her tachycardia persisted and continued to be attributed to her psychiatric disease. On hospital day 5, the patient was found unresponsive and febrile, with worsening tachycardia, tachypnea, and hypoxia; she had diffuse myoclonus and increased muscle tone. She was transferred to the ICU of the hospital, where a chest CT scan revealed bilateral pulmonary emboli (explaining the tachycardia and hypoxia), and clinicians also diagnosed neuroleptic malignant syndrome (a rare and life-threatening reaction to some psychiatric medications).
Elise Orvedal Leiten, MD, and Rune Nielsen, MD, PhD; January 2019
Hospitalized in the ICU with hypoxic respiratory failure due to community-acquired pneumonia, an elderly man had increased pulmonary secretions on hospital day 2 for which the critical care provider decided to perform bedside bronchoscopy. Following the procedure, the patient was difficult to arouse, nearly apneic, and required intubation. The care team paused and discovered that after the patient had received 2 mg of intravenous midalozam, his IV line had been flushed with an additional 10 mg of the benzodiazepine, rather than the intended normal saline. This high dose of midazolam led to the respiratory failure requiring intubation. On top of that, instead of normal saline, lidocaine had been used for the lung lavage.
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.
- Spotlight Case
Ifedayo Kuye, MD, MBA, and Chanu Rhee, MD, MPH; October 2018
Admitted with generalized weakness, nausea, and low blood pressure, an elderly man was given IV fluids and broad spectrum antibiotics. Laboratory test results revealed a mildly elevated white count, acute kidney injury, and elevated liver function tests. The patient was admitted to the medical ICU with a presumed diagnosis of septic shock. His blood pressure continued to trend downward. While reviewing the emergency department test results, the ICU resident noticed the patient's troponin level was markedly elevated and his initial ECG revealed T-wave inversions. A repeat ECG in the ICU showed obvious ST segment elevations, diagnostic of an acute myocardial infarction. The resident realized that the patient's low blood pressure was likely due to the myocardial infarction, not septic shock. He underwent urgent cardiac catheterization and was found to have complete occlusion of the right coronary artery, for which a stent was placed.
Thomas J. Balcezak, MD, MPH, and Ohm Deshpande, MD; October 2018
An elderly man presented to the emergency department (ED) with decreased oral intake, fevers, confusion, and falling urine output. Laboratory test results revealed acute-on-chronic renal failure, and an ECG showed tall T waves, potentially a sign of severe hyperkalemia and a precursor of a dangerous arrhythmia. The ED physician initiated treatment for hyperkalemia, and the on-call intensivist and nephrologist agreed the patient needed urgent hemodialysis. Although they planned to place a hemodialysis catheter and start dialysis as soon as possible, the ICU was full and the patient was forced to "board" in the ED. On arrival to the ICU, 5 hours after the initial labs, the patient was hypotensive and unarousable. The patient went into cardiac arrest, was intubated, and received urgent treatment for hyperkalemia. The nephrologist arrived and was surprised the hemodialysis had not been started. The dialysis nurse had been told to start the dialysis after the patient arrived in the ICU but was unaware of the urgency of the situation.
- Spotlight Case
David J. Lucier, MD, MBA, MPH, and Jeffrey L. Greenwald, MD; September 2018
An older woman with lung cancer that had metastasized to the brain was admitted to the hospital and found to have Pneumocystis jiroveci pneumonia (PJP pneumonia), invasive pulmonary aspergillus, diffuse myopathy, and gastrointestinal bleeding. Medication reconciliation revealed that she had been prescribed a high dose of dexamethasone to reduce the brain swelling associated with the cancer. Although the intention had been to taper the steroids after she received radiotherapy for her brain metastases, the corticosteroids were never tapered, and she continued to take high-dose steroids for more than 2 months. Physicians believed that all of her acute issues were a result of the mistakenly high dose of the steroids.
Jason Bergsbaken, PharmD; September 2018
A woman with cancer was admitted to begin a chemotherapy cycle of IV etoposide (daily for 3 days) and IV cisplatin (single dose). At the hospital's cancer center satellite pharmacy, the pharmacist entered the order into the computer and prepared the first dose of the medications. While transcribing the order, the pharmacist inadvertently switched the duration of therapy for the two agents. The transposition did not affect the patient's first day of therapy. The second day fell on a Saturday, when the satellite pharmacy was closed; a different pharmacist who did not have access to the original chemotherapy order prepared the therapy order. Cisplatin was labeled, dispensed, and reached the bedside. The nurse bypassed the double-check policy for verifying the order prior to administration, and the patient received the second dose of cisplatin instead of the intended dose of etoposide.
Jessica Katznelson, MD; September 2018
In a simulated cardiac resuscitation case of a 5-year-old boy found pulseless and apneic in the bathtub by a parent, many interprofessional teams had difficulty with resuscitation due to a lack of interoperability between the prestocked disposable laryngoscope blades and handles on the Broselow cart (a proprietary system designed to facilitate finding appropriate-sized equipment for pediatric patients requiring lifesaving interventions) with the emergency department's actual stock of blades and handles. This incompatibility led to significant delays and some failures to intubate. Teams often did not recognize the incompatibility and spent unnecessary time replacing batteries while others called for backup airway teams.
- Spotlight Case
Jeffrey Jim, MD, MPHS; August 2018
An older man with multiple medical conditions and an extensive smoking history was admitted to the hospital with worsening shortness of breath. He underwent transthoracic echocardiogram, which demonstrated severe aortic stenosis. The cardiology team recommended cardiac catheterization, but the interventional cardiologist could not advance the catheter and an aortogram revealed an abdominal aortic aneurysm (AAA) measuring 9 cm in diameter. Despite annual visits to his primary care physician, he had never undergone screening ultrasound to assess for presence of an AAA. The patient was sent emergently for surgical repair but had a complicated surgical course.
Giovanni Elia, MD; Susan Barbour, RN, MS; and Wendy G. Anderson, MD, MS; August 2018
Hospitalized in the ICU after cardiac arrest and loss of cardiac function for 15 minutes, an older man experienced worsening neurological status. After extensive discussions about goals of care, the family agreed to a DNR order. Over the next week, his condition declined, and the family decided to transition to comfort measures. Orders were written but shortly thereafter, the family spoke with the ICU resident and reversed their decision. The resident canceled the terminal extubation orders without communicating the order change to other team members. Another nurse found the canceled orders, thought it was an error, and asked another physician (who was also unaware of the change in plans) to reinstate the orders. The patient was extubated and died a few hours later.
Helen Pervanas, PharmD, RPh, and David VanValkenburgh; August 2018
Admitted to different hospitals multiple times for severe hypoglycemia, an older man underwent an extensive workup that did not identify a corresponding diagnosis. During his third hospitalization in 6 weeks, once his glucose level normalized, the care team believed the patient was ready for discharge, but the consulting endocrinologist asked the family to bring in all the patients' medication bottles. The family returned with 12 different medications, none of which were labeled as an oral hypoglycemic agent. The resident used the codes on the tablets to identify them and discovered that one of the medications, labeled an antihypertensive, actually contained oral hypoglycemic pills. As the patient had no history of diabetes, this likely represented a pharmacy filling error.
- Spotlight Case
Resa E. Lewiss, MD; July 2018
After an emergency department (ED) physician interpreted results of a point-of-care ultrasound as showing stable low ejection fraction, some volume overload, and a mechanical mitral valve in place without regurgitation for a man with a history of congestive heart failure, end-stage renal disease, and mechanical mitral valve replacement who presented with shortness of breath, the patient was admitted with a presumed diagnosis of volume overload. Reassured by the ED physician's interpretation of the ultrasound, the hospitalist ordered no further cardiac testing. The patient underwent hemodialysis, felt better, and was discharged. Less than 12 hours later, the patient returned critically ill and in cardiogenic shock. An emergency transthoracic echocardiogram found a thrombosed mitral valve, which had led to acute mitral stenosis and cardiogenic shock.
Rita L. McGill, MD, MS; July 2018
Admitted to the hospital with an ulcer on his right foot, a man with diabetes and stage IV chronic kidney disease had an MRI concerning for osteomyelitis, and a bone biopsy showed chronic inflammation with cultures positive for methicillin-sensitive Staphylococcus aureus. To administer outpatient parenteral antimicrobial therapy, interventional radiology attempted to place a peripherally inserted central catheter (PICC) in the right brachial vein multiple times but failed. They then placed it in the left brachial vein. The patient completed 6 weeks of antibiotic therapy and wound care, and the PICC was removed. Five months later with worsening renal function and hyperphosphatemia, the patient required dialysis access, but he was not a candidate for arteriovenous fistula placement since the many venipuncture attempts during PICC placement resulted in poor vein quality.
Deborah Debono, PhD, RN, and Tracy Levett-Jones, PhD, RN; July 2018
A young adult with a progressive neurological disorder presented to an emergency department from a nursing home with a dislodged GJ tube. As a workaround to maintain patency when the GJ tube was dislodged, nursing home staff had inserted a Foley catheter into the ostomy, inflated the Foley bulb in the stomach, and tied the distal portion of the catheter in a loose knot. When the patient went to interventional radiology for new GJ tube placement, clinicians found no Foley but inserted a new GJ tube. Discharged to the nursing home, the patient was readmitted 2 days later with fever and increasing abdominal distention. An abdominal CT scan showed an obstructing foreign body in the small bowel.
- Spotlight Case
A. Clinton MacKinney, MD, MS, and Nicholas M. Mohr, MD, MS; June 2018
After presenting to a rural emergency department with chest pain, a man with a history of diabetes awaited admission to the hospital. The off-site admitting internist ordered aspirin and a heparin drip, but neither medication was administered. On transfer to the acute care unit 2 hours later, the patient was diaphoretic, somnolent, tachycardic, and borderline hypotensive. The nurse called the internist and realized the heparin drip had never been started. When she went to administer it, the patient was unresponsive, hypotensive, and bradycardic. She called a code blue.
Jennifer Faig, MD, and Jessica A. Zerillo, MD, MPH; June 2018
Admitted to the oncology service for chemotherapy treatment, a woman with leukemia was noted to be neutropenic on hospital day 6. She had some abdominal discomfort and had not had a bowel movement for 2 days. The overnight physician ordered a suppository without realizing that the patient was neutropenic and immunosuppressed. Unaware that suppositories are contraindicated in neutropenic patients, the nurse administered the suppository. The patient developed a fever soon after receiving the suppository and required transfer to the intensive care unit for hypotension and management of septic shock.
Joseph L. Schindler, MD; June 2018
Brought to the emergency department after being found unresponsive, an older man was given systemic thrombolytics to treat a suspected stroke. After administering the medication, the nurse noticed patches on the patient's back. The patient's wife explained that the patches, which contained fentanyl and whose doses had recently been increased, were for chronic back pain. In fact, the wife had placed two patches that morning. Medication reconciliation revealed that the patient had inadvertently received 3 times his previous dose. He was administered naloxone to treat the opioid overdose. Although he became more responsive, he had a generalized seizure and a CT showed intracranial hemorrhage—an adverse consequence of the thrombolytics.