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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Complaints as Safety Surveillance

Jennifer Morris and Marie Bismark, MD; September 2016

Assuming its dosing was similar to morphine, a physician ordered 4 mg of IV hydromorphone for a hospitalized woman with pain from acute pancreatitis. As 1 mg of IV hydromorphone is equivalent to 4 mg of morphine, this represented a large overdose. The patient was soon found unresponsive and apneic—requiring ICU admission, a naloxone infusion overnight, and intubation. While investigating the error, the hospital found other complaints against that particular physician.

Wrong-Time Error With High-Alert Medication

Annie Yang, PharmD, and Lewis Nelson, MD; September 2016

Admitted for knee surgery, a man was given his medications at 10 PM, including oral dofetilide (an antiarrhythmic agent with a strict 12-hour dosing interval). In the electronic health record, "q12 hour" drugs are scheduled for 6 AM and 6 PM by default. Because the patient was scheduled to leave for the operating room before 6 AM, the nurse gave the dose at 4 AM. Preoperative ECG revealed he had severe QTc prolongation (putting him at risk for a fatal arrhythmia), and surgery was canceled.

More Treatment—Better Care?

Rita Redberg, MD, MSc; December 2011

A patient with Guillain-Barré syndrome received more than the recommended number of plasmapheresis treatments. When the ordering physicians were asked why so many treatments were given, they both responded that the patient was improving so they felt that more treatments would help him recover even more.

Duty to Disclose Someone Else's Error?

  • Spotlight Case

Thomas H. Gallagher, MD; May 2011

Transferred to a tertiary hospital, a child with severe swelling of the brain is found to have venous sinus thromboses and little chance of survival. Further review revealed that the referring hospital had missed subtle signs of cerebral edema on the initial CT scan days earlier, raising the question of whether to disclose the errors of other facilities or caregivers.

Outbreak

Richard Rothman, MD, PhD; Sahael Stapleton, MD; May 2011

An emergency department worker develops chicken pox following an exposure during one of his shifts.

Are We Pushing Graduate Nurses Too Fast?

Nancy Spector, PhD, RN ; March 2011

While caring for a complex patient in the surgical intensive care unit, a nurse incorrectly set up the continuous renal replacement therapy (CRRT) machine, raising questions about how new nurses should be trained in high-risk procedures.

One Toxic Drug Is Not Like Another

  • Spotlight Case

Eric S. Holmboe, MD; February 2011

A man diagnosed with chronic hepatitis C was treated with interferon and ribavirin by his internist without referral for a liver biopsy or the appropriate blood tests. Treatment was continued for months despite the patient developing pancytopenia and continuing to have a high viral load, raising questions about physicians practicing outside their areas of competency.

The Forgotten Turn

  • Spotlight Case

Susan Barbour, RN, MS, FNP; December 2010

Admitted to the hospital with right-hip and left-arm fractures, an elderly woman remained on the same bed from the emergency department for nearly 16 hours and developed a moderate-sized, stage 2 pressure ulcer.

"Recurrent" Appendicitis

Caprice C. Greenberg, MD, MPH; October 2010

Following an appendectomy, an elderly man continued to have right lower quadrant pain. Reviewing the specimen removed during the surgery, the pathologist found no appendiceal tissue. The patient was emergently taken back to the OR, and the appendix was located and removed.

Defensive Medicine: "Glowing" with Pain

Manish K. Sethi, MD; February 2010

Over the course of 2 years, a patient who frequently came to the emergency department complaining of abdominal pain underwent 12 CT scans of the abdomen and pelvis. All of them were completely normal.

Round-Trip Service

Mary H. McGrath, MD, MPH; December 2009

Eager to have his knee replaced, an active older patient travels overseas for the surgery. At home 2 weeks later, he develops acute pain and swelling in his knee. A local orthopedic surgeon's office tells him to contact his operating physician, nearly 5000 miles away.

Difficult Encounters: A CMO and CNO Respond

  • Spotlight Case

Ernest J. Ring, MD; Jane E. Hirsch, RN, MS; October 2009

Cardiology consultation on an elderly man admitted to the orthopedic service following a hip fracture reveals aortic stenosis. The cardiologist recommends against surgery, due to the risk of anesthesia. When the nurse reads these recommendations to the orthopedic resident, he calls her "stupid" and contacts the OR to schedule the surgery anyway. The Chief Medical Officer is called to intervene.

All in the History

  • Spotlight Case

Christopher Fee, MD; February-March 2009

Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.

To Transfer or Not to Transfer

  • Spotlight Case

Jesse M. Pines, MD, MBA, MSCE; January 2009

An elderly man, recently discharged from one hospital after having his automated internal cardioverter-defibrillator (AICD) replaced, is taken to another hospital when his AICD misfires multiple times.

Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad

  • Spotlight Case

Sumant Ranji, MD; April 2008

A woman with symptoms of sinusitis was given 2 different courses of broad-spectrum antibiotics, neither of which improved her symptoms. Hospitalized for autoimmune hemolysis (presumably from the antibiotic), the patient suffered multiorgan failure and septic shock, and died.

The Wrongful Resuscitation

Joan M. Teno, MD, MS; April 2008

Despite having a signed DNR (do not resuscitate) form, an elderly man brought to the emergency department with severe pain was rushed to the operating room for urgent abdominal aortic aneurysm repair.

Code Blue—Where To?

Bruce D. Adams, MD; October 2007

A code blue is called on an elderly man with a history of coronary artery disease, hypertension, and schizophrenia hospitalized on the inpatient psychiatry service. Housestaff covering the code team did not know where the service was located, and when the team arrived, they found their equipment to be incompatible with the leads on the patient.

Abnormal Volunteer Results

Conrad V. Fernandez, MD; June 2007

A healthy woman who volunteered to participate in a radiology study was notified several weeks later of a "major abnormality" discovered on her MRI. She sought further evaluation and was diagnosed with uterine cancer.

Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality

  • Spotlight Case

Peter Lindenauer, MD, MSc; November 2006

A woman with end stage renal disease and heart disease on anticoagulation receives a pneumonia vaccination that causes a large hematoma.

Liposuction Gone Awry

James A. Yates, MD; March 2006

A man undergoes plastic surgery at an outpatient center and winds up with a complication requiring prolonged stay in the ICU.

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