WebM&M Cases & Commentaries

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One Bronchoscopy, Two Errors

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.

Primary Workaround, Secondary Complication

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.

Root Cause Analysis Gone Wrong

Mohammad Farhad Peerally, MBChB, MRCP, and Mary Dixon-Woods, DPhil; May 2018

For a man with end-stage renal disease, a transplanted kidney was connected successfully. As the surgery was nearing completion, the surgeon instructed the anesthesiologist to give 3000 units of heparin. When preparing to close the incision, the clinicians noticed severe bleeding. The patient's blood pressure dropped, and transfusions were administered while they tried to stop the bleeding. The anesthesiologist mistakenly had administered 30,000 units of heparin. Although the surgical team administered protamine to reverse the anticoagulant effect, the bleeding and hypotension had irreversibly damaged the transplanted kidney.

Shortcuts to Acetaminophen-induced Liver Failure

Stephen Bacak, DO, MPH, and Loralei Thornburg, MD; March 2018

A pregnant woman presented to the emergency department 3 times in 4 days, first with symptoms of upper respiratory infection, nausea, and fever; then abdominal cramps; then shortness of breath and abdominal pain. On the third visit, she was diagnosed with influenza and possible sepsis. In between visits, the patient had been taking acetaminophen (1g every 4 hours) to control her fever. Although she had signs of acute fulminant hepatitis due to acetaminophen overdose, administration of the antidote, N-acetylcysteine, was delayed for 10 hours.

Right Place, Right Drug, Wrong Strength

Valentina Jelincic, RPh, and Julie Greenall, RPh, MHSc; February 2018

A hospitalized pediatric burn patient underwent dressing changes and burn inspection every third day. On those days she received oxycodone for pain, which allowed her to tolerate the painful procedures and to rest. After a dressing change one day, the mother noticed the child's breathing was shallow. That day the patient had received three doses of oxycodone, but because the automated dispensing machine had been stocked incorrectly with a higher concentration of oxycodone solution stored in the location normally reserved for the lower concention, she received nearly five times the dose ordered.

Palliative Care: Comfort vs. Harm

Spotlight Case
CE/MOC

Ralf Jox, MD, PhD; November 2017

An older man admitted for the third time in 4 weeks for an exacerbation of congestive heart failure expressed his wishes to focus on comfort and pursue hospice care. Comfort measures were initiated and other treatments were stopped. The care team wrote for a standing dose of IV hydromorphone every 4 hours. The night shift nurse administered the scheduled dose at 3:00 AM. At 7:00 AM, the palliative care attending found the patient obtunded, with shallow respirations and a low respiratory rate.

High-Risk Medications, High-Risk Transfers

Nancy Staggers, PhD, RN; October 2017

Hospitalized with sepsis secondary to an infected IV line through which she was receiving treprostnil (a high-alert medication used to treat pulmonary hypertension), a woman was transferred to interventional radiology for placement of a new permanent catheter once the infection cleared. Sign-off between departments included a warning not to flush the line since it would lead to a dangerous overdose. However, while attempting to identify an infusion pump alarm, a radiology technician accidentally flushed the line, which led to a near code situation.

Hyperbilirubinemia Refractory to Phototherapy

Vinod K. Bhutani, MD, and Ronald J. Wong; October 2017

A newborn with elevated total serum bilirubin (TSB) due to hemolytic disease was placed on a mattress with embedded phototherapy lights for treatment, but the TSB continued to climb. The patient was transferred to the neonatal ICU for an exchange transfusion. The neonatologist requested testing of the phototherapy lights, and their irradiance level was found to be well below the recommended level. The lights were replaced, the patient's TSB level began to drop, and the exchange transfusion was aborted.

Despite Clues, Failed to Rescue

Spotlight Case
CE/MOC

Amir A. Ghaferi, MD, MS; August 2017

Admitted to gynecology due to excess bleeding and low hemoglobin after elective surgery, an older woman developed severe pain, nausea, and new-onset atrial fibrillation. She was moved to the telemetry unit where cardiologists treated her, and she had episodes of bloody vomit. Intensivists consulted, but the patient arrested while being transferred to the ICU and died despite maximal efforts.

The Perils of Contrast Media

Spotlight Case
CE/MOC

Umar Sadat, MD, PhD, and Richard Solomon, MD; June 2017

To avoid worsening acute kidney injury in an older man with possible mesenteric ischemia, the provider ordered an abdominal CT without contrast, but the results were not diagnostic. Shortly later, the patient developed acute paralysis, and an urgent CT with contrast revealed blockage and a blood clot.

Chest Tube Complications

Lekshmi Santhosh, MD, and V. Courtney Broaddus, MD; June 2017

A woman with pneumothorax required urgent chest tube placement. After she showed improvement during her hospital stay, the pulmonary team requested the tube be disconnected and clamped with a follow-up radiograph 1 hour later. However, 3 hours after the tube was clamped, no radiograph had been done and the patient was found unresponsive, in cardiac arrest.

Diagnostic Overshadowing Dangers

Maria C. Raven, MD, MPH, MSc; June 2017

Presenting with pain in her epigastric region and back, an older woman with a history of opioid abuse had abnormal vital signs and an elevated troponin level. Imaging revealed multiple spinal fractures and cord compression. Neurosurgery recommended conservative management overnight. However, her troponin levels spiked, and an ECG revealed myocardial infarction.

Diagnostic Delay in the Emergency Department

Spotlight Case
CE/MOC

Kyle Marshall, MD, and Hardeep Singh, MD, MPH; May 2017

Emergency department evaluation of a man with morbid obesity presenting with abdominal pain revealed tachycardia, hypertension, elevated creatinine, and no evidence of cholecystitis. Several hours later, the patient underwent CT scan; the physicians withheld contrast out of concern for his acute kidney injury. The initial scan provided no definitive answer. Ultimately, physicians ordered additional CT scans with contrast and diagnosed an acute aortic dissection.

Hemolysis Holdup

Christopher M. Lehman, MD; May 2017

In the emergency department, an older man with multiple medical conditions was found to have evidence of acute kidney injury and an elevated serum potassium level. However, the blood sample was hemolyzed, which can alter the reading. Although the patient was admitted and a repeat potassium level was ordered, the physician did not institute treatment for hyperkalemia. Almost immediately after the laboratory called with a panic result indicating a dangerously high potassium level, the patient went into cardiac arrest.

Wrong-side Bedside Paravertebral Block: Preventing the Preventable

Michael J. Barrington, MBBS, PhD, and Yoshiaki Uda, MBBS; April 2017

An older woman admitted to the medical-surgical ward with multiple right-sided rib fractures received a paravertebral block to control the pain. After the procedure, the anesthesiologist realized that the block had been placed on the wrong side. The patient required an additional paravertebral block on the correct side, which increased her risk of complications and exposed her to additional medication.

Consequences of Medical Overuse

Spotlight Case
CE/MOC

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.

Diagnosing a Missed Diagnosis

James B. Reilly, MD, MS, and Christopher Webster, DO; March 2017

A woman taking modified-release lithium for bipolar disorder was admitted with cough, slurred speech, confusion, and disorientation. Diagnosed with delirium attributed to hypercalcemia, she was treated with aggressive hydration. She remained disoriented and eventually became comatose. After transfer to the ICU, she was diagnosed with nephrogenic diabetes insipidus due to lithium toxicity.

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.

An Obstructed View

Jonathan Carter, MD; October 2015

A patient with severe abdominal pain was admitted to the medicine service for observation, pain control, and serial abdominal examinations. Surgical consultation was not requested at admission. Two days later, the patient's abdomen worsened. Consultation led to urgent surgery, which revealed a strangulating bowel obstruction and associated perforation.

Fire in the Hole!—An OR Fire

Sonya P. Mehta, MD, MHS, and Karen B. Domino, MD, MPH; April 2015

During laparoscopic subtotal colon resection for adenocarcinoma, a patient's bladder was accidentally lacerated and surgeons repaired it without difficulty. As nurses set up bladder irrigation equipment, no one noticed the bag of solution was dripping into the power supply of an anesthesiology monitor. Suddenly sparks and flames began shooting from the monitor, and the OR filled with black smoke. Fortunately, the fire was extinguished quickly and neither the patient nor any OR staff was injured.