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 between Providers 38
- Culture of Safety 12
Education and Training
- Students 4
Error Reporting and Analysis
- Error Analysis 13
Human Factors Engineering
- Checklists 13
- Legal and Policy Approaches 11
- Logistical Approaches 9
Quality Improvement Strategies
- Reminders 12
- Specialization of Care 11
- Teamwork 7
- Clinical Information Systems 22
- Alert fatigue 2
- Device-related Complications 20
- Diagnostic Errors 53
- Discontinuities, Gaps, and Hand-Off Problems 46
- Drug shortages 1
- Fatigue and Sleep Deprivation 1
- Identification Errors 7
- Inpatient suicide 1
- Interruptions and distractions 3
- Delirium 2
- Medication Errors/Preventable Adverse Drug Events 39
- MRI safety 1
- Nonsurgical Procedural Complications 23
- Psychological and Social Complications 9
- Second victims 1
- Surgical Complications 22
- Transfusion Complications 2
- Ambulatory Care 27
- Hospitals 140
- Long-Term Care 2
- Outpatient Surgery 5
- Patient Transport 1
- Psychiatric Facilities 3
- Allied Health Services 1
- Gynecology 25
- Cardiology 14
- Geriatrics 11
- Obstetrics 10
- Pediatrics 12
- Primary Care 12
- Radiology 10
- Nursing 21
- Palliative Care 3
- Pharmacy 8
- Health Care Executives and Administrators 78
Health Care Providers
- Nurses 19
- Physicians 44
- Non-Health Care Professionals 38
- Patients 6
Stephanie Rogers, MD, and Derek Ward, MD; April 2019
An elderly man with a complicated medical history slipped on a rug at home, fell, and injured his hip. Emergency department evaluation and imaging revealed no head injury and a left intertrochanteric hip fracture. Although he was admitted to the orthopedic surgery service, with surgery to fix the fracture initially scheduled for the next day, the operation was delayed by 3 days due to several emergent trauma cases and lack of surgeon availability. He ultimately underwent surgery and was discharged a few days later but was readmitted several weeks later with chest pain and shortness of breath. He was found to have a pulmonary embolism; anticoagulation was initiated. The patient's rehabilitation was delayed, his recovery was prolonged, and he never returned to his baseline functional status.
- Spotlight Case
C. Craig Blackmore, MD, MPH; March 2019
A woman with multiple myeloma required placement of a central venous catheter for apheresis. The outpatient oncologist intended to order a nontunneled catheter via computerized provider order entry but accidentally ordered a tunneled catheter. The interventional radiologist thought the order was unusual but didn't contact the oncologist. A tunneled catheter was placed without complications. When the patient presented for apheresis, providers recognized the wrong catheter had been placed, and the patient underwent an additional procedure.
Rommel Sagana, MD, and Robert C. Hyzy, MD; March 2019
Following an elective carotid endarterectomy, an elderly woman was extubated in the operating room (OR) and brought to the recovery area. She soon developed respiratory distress necessitating urgent reintubation, which required multiple attempts. She was found to have an expanding neck hematoma, which was drained safely in the OR. Later that day after a half hour weaning trial, the respiratory therapist extubated the patient without checking for a cuff leak. Within 15 minutes, she developed acute shortness of breath and stridor, which rapidly progressed to hypoxemic respiratory failure. Urgent reintubation was difficult because her vocal cords were edematous.
Nicole M. Acquisto, PharmD, and Daniel J. Cobaugh, PharmD; March 2019
Seen in the emergency department, a man with insulin-dependent diabetes mellitus had not taken insulin for 3 days. His blood glucose levels were in the 800s with an anion-gap acidosis and positive beta hydroxybutyrate. While awaiting an ICU bed for treatment of diabetic ketoacidosis, the patient received fluids, an insulin drip was started, and blood glucose levels were monitored hourly. When lab results showed he was improving, the team decided to convert his insulin drip to subcutaneous long-acting insulin. However, both the intern and the resident ordered 50 units of insulin, and the patient received both doses—causing his blood glucose level to dip into the 30s.
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).
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.
Steven Plogsted, PharmD; October 2018
A 1-month-old preterm infant in the NICU receiving the standard 500 mL bag of 0.45% sodium chloride (NaCl) with heparin at low rates developed hyponatremia. Clinicians recognized the need to deliver a more concentrated sodium solution and ordered that the IV fluid be changed to a 500 mL bag of 0.9% NaCl with heparin. However, due to a natural disaster affecting the supply chain for IV fluids, 0.9% NaCl 500 mL bags were in short supply, and the order was modified to use 100 mL 0.9% NaCl bags, which were available. Since the total volume was much smaller, a lower concentration formulation of heparin was required. However, the verifying pharmacist discovered that an 10-fold higher concentration had been used to compound the fluids, and further investigation revealed this same error had occurred on five other occasions.
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.
- 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.
- Spotlight Case
Daniel J. Morgan, MD, MS, and Andrew Foy, MD; March 2017
Brought to the emergency department from a nursing facility with confusion and generalized weakness, an older woman was found to have an elevated troponin level but no evidence of ischemia on her ECG. A consulting cardiologist recommended treating the patient with three anticoagulants. The next evening, she became acutely confused and a CT scan revealed a large intraparenchymal hemorrhage with a midline shift.
Osama Loubani, MD; January 2017
A man with a history of cardiac disease was brought to the emergency department for septic shock of possible intra-abdominal origin. A vasopressor was ordered. However, rather than delivering it through a central line, the norepinephrine was infused through a peripheral line. The medication extravasated into the subcutaneous tissue of the patient's arm. Despite attempts to salvage the patient's wrist and fingers, three of his fingertips had to be amputated.
Chris Vincent, PhD; December 2016
Admitted to the hospital for treatment of a hip fracture, an elderly woman with end-stage dementia was placed on the hospice service for comfort care. The physician ordered a morphine drip for better pain control. The nurse placed the normal saline, but not the morphine drip, on a pump. Due to the mistaken setup, the morphine flowed into the patient at uncontrolled rate.
Jennifer Merrilees, RN, PhD, and Kirby Lee, PharmD, MA, MAS; May 2016
An elderly man with early dementia fractured his leg and was admitted to a skilled nursing facility for physical therapy. On his third day there, he became delirious and agitated and was taken to the emergency department and hospitalized. A few days later, doctors involuntarily committed him and administered risperidone, which worsened his delirium.
Vineet Chopra, MD, MSc; February 2016
Hospitalized with poorly controlled diabetes, a man had a peripherally inserted central catheter (PICC) placed for intravenous pain medications, intravenous fluids, and parenteral nutrition. The next day, the patient complained of headache, unilateral vision loss, and left-sided tingling and numbness. Misplacement of the PICC in a left-sided superior vena cava had led to embolic strokes.
- Spotlight Case
Kevin M. Barrett, MD, MSc; December 2014
An elderly man admitted for a presumed hypertensive emergency and undiagnosed neurologic symptoms became unresponsive and was noted to have new right hand weakness 2 days into his hospitalization. After a "Code Stroke" was called, a neurologist evaluated him and administered tPA 100 minutes after the acute event. A few hours later, the patient developed further symptoms, and an emergent head CT demonstrated post-tPA intracerebral hemorrhage.
- 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.
Delphine Tuot, MDCM, MAS; September 2014
A patient with ALS was hospitalized with presumed pneumonia and sepsis. Although he was treated with broad-spectrum antibiotics and fluid resuscitation, additional potassium was administered due to his potassium level remaining low. The patient went into cardiac arrest and resuscitation attempts were unsuccessful.
- Spotlight Case
Terence Goh, MBBS, and Lee Gan Goh, MBBS; July-August 2014
Admitted with bruising from a fall and persistent pain on his left side, a patient was kept in the emergency department overnight due to crowding. After being reevaluated by the surgical service the next day, the patient was urgently taken to the operating room for probable necrotizing fasciitis and pyomysitis.