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 between Providers 47
- Culture of Safety 16
Education and Training
- Students 4
Error Reporting and Analysis
- Error Analysis 15
Human Factors Engineering
- Checklists 17
- Legal and Policy Approaches 12
- Logistical Approaches 18
- Policies and Operations 2
- Quality Improvement Strategies 39
- Specialization of Care 11
- Teamwork 10
- Clinical Information Systems 32
- Alert fatigue 3
- Device-related Complications 6
- Diagnostic Errors 23
- Discontinuities, Gaps, and Hand-Off Problems 41
- Fatigue and Sleep Deprivation 1
- Identification Errors 11
- Inpatient suicide 1
- Interruptions and distractions 7
- Medical Complications 11
- Medication Errors/Preventable Adverse Drug Events 38
- MRI safety 2
- Nonsurgical Procedural Complications 6
- Psychological and Social Complications 12
- Surgical Complications 14
- Transfusion Complications 1
- Allied Health Services 1
- Gynecology 12
- Internal Medicine 26
- Surgery 22
- Nursing 17
- Pharmacy 6
- Health Care Executives and Administrators 57
Health Care Providers
- Nurses 16
- Physicians 21
- Non-Health Care Professionals 56
- Patients 3
Neal L. Benowitz, MD; April 2019
A woman who required oxygen at home via nasal cannula and used a continuous positive airway pressure (CPAP) machine at night was admitted for an exacerbation of chronic obstructive pulmonary disease without any signs of infection. During her hospital stay, she continued to require 5 liters of oxygen by nasal cannula. Although the patient had received smoking cessation education and no longer smoked regular cigarettes, she did continue to vape with an electronic cigarette (e-cigarette). Having not been told to avoid vaping in the hospital, the patient took a puff on her e-cigarette while she was receiving oxygen through her nasal cannula and sparked an explosion. She ripped off the nasal cannula, which had melted, and sustained burns to her face and hand, resulting in a prolonged hospitalization for burn care and extensive pain management.
- 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.
Brian Clay, MD; January 2019
Following urgent catheter-directed thrombolysis to relieve acute limb ischemia caused by thrombosis of her left superficial femoral artery, an elderly woman was admitted to the ICU. While ordering a heparin drip, the resident was unaware that the EHR order set had undergone significant changes and inadvertently ordered too low a heparin dose. Although the pharmacist and bedside nurse noticed the low dose, they assumed the resident selected the dose purposefully. Because the patient was inadequately anticoagulated, she developed extensive thrombosis associated with the catheter and sheath site, requiring surgical intervention for critical limb ischemia (including amputation of the contralateral leg above the knee).
- Spotlight Case
Olle ten Cate, PhD; November 2018
An ICU patient with head and spine trauma was sent for an MRI. Due his critical condition, hospital policy required a physician and nurse to accompany the patient to the MRI scanner. The ICU attending assigned a new intern, who felt unprepared to handle any crises that might arise, to transport the patient along with the nurse. While in a holding area awaiting the MRI, the patient's heart rate fell below 20 beats per minute, and the experienced ICU nurse administered atropine to recover his heart rate and blood pressure. The intern worried he had placed the patient's life at risk because of his inexperience, but he also felt uncomfortable speaking up.
Kheyandra Lewis, MD, and Glenn Rosenbluth, MD; November 2018
Early in the academic year, interns were on their first day of a rotation caring for an elderly man hospitalized for a stroke, who had developed aspiration pneumonia and hypernatremia. When the primary intern signed out to the cross-cover intern, he asked her to check the patient's sodium level and replete the patient with IV fluids if needed. Although the cross-covering intern asked for more clarification, the intern signing out assured her the printed, written signout had all the information needed. Later that evening, the patient's sodium returned at a level above which the written signout stated to administer IV fluids, and after reviewing the plan with the supervising resident, the intern ordered them. The next morning the primary team was surprised, stating that the plan had been to give fluids only if the patient was definitely hypernatremic. Confused, the cross-cover intern pointed out the written signout instructions. On further review, the primary intern realized he had printed out the previous day's signout, which had not been updated with the new plan.
The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy
- Spotlight Case
Jacob Reider, MD; October 2015
After leaving Hospital X against medical advice, a man with paraplegia presented to the emergency department of Hospital Y with pain and fever. The patient was diagnosed with sepsis and admitted to Hospital Y for management. In the night, the nurse found the patient unresponsive and called a code blue. The patient was resuscitated and transferred to the ICU, where physicians determined that the arrest was due to acute rupturing of his red blood cells (hemolysis), presumably caused by a reaction to the antibiotic. Later that day, the patient's records arrived from three hospitals where he had been treated recently. One record noted that he had previously experienced a life-threatening allergic reaction to the antibiotic, which was new information for the providers at Hospital Y.
Krishnan Padmakumari Sivaraman Nair, DM; July/August 2015
A 5-year-old boy with transverse myelitis presented to the rehabilitation medicine clinic for scheduled quarterly botulinum toxin injections to his legs for spasticity. Halfway through the course of injections, the patient's mother noted her son was tolerating the procedure "much better than 3 weeks earlier"—the patient had been getting extra injections without the physicians' knowledge. Physicians discussed the risks of too-frequent injections with the family. Fortunately, the patient had no adverse effects from the additional injections.
Jeffrey H. Barsuk, MD, MS, and Cynthia Barnard, MBA, MSJS; December 2014
In a simulation exercise conducted in an institution that felt it was prepared for patients with actual or suspected Ebola, a man presented to the emergency department with symptoms of nausea, vomiting, and fever. He had recently returned to the US from Sierra Leone. The nurse initiated an isolation protocol and the critical care team all donned personal protective equipment. During transport, confusion about which elevators to use potentially exposed 30 staff members to Ebola. Additional issues occurred including breaching sterile technique while inserting a central line and confusion about the process to transport the patient's blood to the lab.
- Spotlight Case
Shoshana J. Herzig, MD, MPH; September 2014
Hospitalized for foot amputation, a man with COPD and chronic pain on long-acting morphine experienced post-operative pain and severe muscle spasms. After being given hydromorphone, morphine, and diazepam, the patient became minimally responsive and a code blue was called.
- Spotlight Case
Thomas A. Smith, CHPA, CPP; June 2014
Hospitalized for alcohol withdrawal, an elderly man was feeling "cooped up" by hospital day 6 and left the floor without informing any providers. An hour later upon return to his room, he complained of new arm pain. While off hospital grounds, the patient had fallen and broken his arm.
- Spotlight Case
Annie Yang, PharmD, BCPS; February 2014
Despite multiple checks by physician, pharmacist, and nurse during the medication ordering, dispensing, and administration processes, a patient received a 10-fold overdose of an opioid medication and a code blue was called.
Karen Ousey, PhD, RGN; February 2014
A patient admitted for acute liver failure, acute renal failure, respiratory failure, and hepatic encephalopathy had a rectal tube placed to manage diarrhea. Two weeks into his hospitalization, dark red liquid stool was noted in the rectal tube, and the patient was found to have a large ulcerated area in the rectum, likely caused by the tube.
Daniel Saddawi-Konefka, MD, and Jeffrey B. Cooper, PhD; December 2013
Prior to coronary artery bypass surgery, a man with morbid obesity, hypertension, diabetes, sleep apnea, claustrophobia, and 3-vessel coronary artery disease was given oxygen to achieve pre-oxygenation. Within a few minutes, the anesthesia team noted the patient was unresponsive with shallow breathing. Further investigation revealed the anesthesia machine was delivering 12% desflurane (a general anesthetic) instead of oxygen alone.
- Spotlight Case
Urmimala Sarkar, MD, MPH; October 2013
Although the mother of a child, born male who identified as and expressed externally as a girl, had alerted the clinic of the child's preferred name when making the appointment, the medical staff called for the patient in the waiting room using her legal (masculine) name.
Melissa Baysari, PhD; October 2013
An epilepsy patient's discharge plan included phenytoin to be taken once daily. The prescribing physician was somewhat unfamiliar with the electronic medical record (EMR), didn't notice that the default frequency for phenytoin was "TID," and overrode the resultant computerized alert about the high dosage.
Erika Abramson, MD, MS, and Rainu Kaushal, MD, MPH; September 2013
After a new electronic health record was introduced without automatically transferring patients' allergy information to the corresponding fields, a woman was given an antibiotic she was allergic to, which resulted in her being admitted to the intensive care unit.
Robin R. Hemphill, MD, MPH; September 2013
Admitted to the hospital after hours, a patient with a history of type A aortic dissection had his CT scan read as "no acute changes." However, the CT scan had been compared to a text report of a previous scan, rather than the images. The patient died several hours later, and autopsy revealed the dissection had progressed and ruptured.
Wendy G. Anderson, MD, MS; February 2012
An elderly man hospitalized with multiple medical conditions decided (with his family's blessing) on a DNR/DNI order. Following treatment, the patient was discharged home. Just days later a paramedic transporting the patient to the emergency department asked the family about advanced directives and they requested that "everything be done."
Ben-Tzion Karsh, PhD; March 2011
A patient requiring orthopedic follow-up after an emergency department visit missed his appointment, and a secretary canceled the referral in the electronic medical record to minimize black marks on the hospital’s 30-day referral quality scorecard. Because the primary physician did not receive notice of the cancellation, follow-up was delayed.
Robert L. Poole, PharmD; Tessa Dixon, PharmD; December 2010
Following a vehicle collision, a man admitted to the hospital was given a twofold overdose of dexamethasone, due to confusion about administration instructions on a multidose vial.