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 Improvement
- Culture of Safety 3
- Education and Training 3
- Error Reporting and Analysis 6
- Human Factors Engineering 6
- Legal and Policy Approaches 1
- Logistical Approaches 3
- Quality Improvement Strategies 5
- Specialization of Care 2
- Teamwork 3
- Clinical Information Systems 4
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 7
- Identification Errors 4
- Interruptions and distractions 2
- Medication Errors/Preventable Adverse Drug Events 6
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 5
- Surgery 4
- Nursing 4
- Pharmacy 1
Kiran Gupta, MD, MPH, and Raman Khanna, MD; July/August 2016
A woman with a history of chronic obstructive pulmonary disease underwent hip surgery and experienced shortness of breath postoperatively. A chest radiograph showed a pneumothorax, but the radiologist was unable to locate the first call physician to page about this critical finding.
Dustin W. Ballard, MD, MBE; David R. Vinson, MD; and Dustin G. Mark, MD; May 2015
A man with a history of poorly controlled diabetes and pancreatic insufficiency was found unresponsive. Paramedics transported him to the emergency department, where a resident placed a right internal jugular line for access but was unable to confirm placement. The resident pulled the line, opened a second line insertion kit, started over, and confirmed placement with ultrasound. The patient went into cardiac arrest, and a chest radiograph noted a retained guidewire in the pulmonary artery.
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.
- Spotlight Case
by John G. DeVine, MD; March 2015
A man with suspected renal cell carcinoma seen on CT in the right kidney was transferred to another hospital for surgical management. The imaging was not sent with him, but hospital records, which incorrectly documented the tumor as being on the left side—were. The second hospital did not obtain repeat imaging, and the surgeon did not see the original CT prior to removing the wrong kidney.
Kerm Henriksen, PhD; Kendall K. Hall, MD, MS; June 2011
Admitted to the hospital with community-acquired pneumonia, an elderly man nearly receives dangerous potassium supplementation due to a “critical panic value” call for a low potassium in another patient.
Leslie W. Hall, MD; October 2008
Orthopedic surgeons rounding on an elderly Cantonese-speaking woman recommend conservative, nonsurgical treatment for her broken hip, as their examination noted that the patient was able to walk. Given that strict bed rest orders were in place for this patient, a medical intern found the note peculiar. Further investigation revealed that the surgeons had actually walked the patient's roommate, another Cantonese-speaking woman.
David L. Feldman, MD, MBA; May 2008
Prior to surgery, an anesthesiologist and surgical physician assistant noted a patient's allergy to IV contrast dye, but no order was written. During a time out before the procedure, an operative nurse raised concern about the allergy, but the attending anesthesiologist was not present and the resident did not speak up.
Richard A. Smith, DDS; July-August 2007
A patient underwent tooth extraction, but awoke from anesthesia and found that the wrong two teeth had been removed.
- Spotlight Case
Arpana R. Vidyarthi, MD; September 2006
An elderly man was admitted to the hospital for pacemaker placement. Although the postoperative chest film was normal, the patient later developed shortness of breath. Over the course of several nursing and physician shift changes and signouts, results of a follow-up stat x-ray are not properly obtained, delaying discovery of the patient's pneumothorax.
Saul N. Weingart, MD, PhD; August 2006
In the office, a man with diabetes has high blood sugar, and the nurse practitioner orders insulin. After administration, she discovers that she has injected the insulin with a tuberculin syringe rather than an insulin syringe, resulting in a 10-fold overdose.
- Spotlight Case
Scott A. Flanders, MD; Sanjay Saint, MD, MPH; June 2005
Using a case of a dosing error, the authors describe the best practices in performing a root cause analysis.
Arpana Vidyarthi, MD; March 2004
Due to a series of incomplete signouts, information about a patient's post-operative leg pain and chest discomfort is not conveyed to the primary team. A PE is discovered post-mortem.
Timothy S. Lesar, PharmD; November 2003
An unclear verbal order leads to administration of the wrong drug.
Robert M. Wachter, MD; October 2003
A missing lab result leads to a 6-month delay in informing a patient about a new diagnosis of HIV.
- Spotlight Case
Matthew B. Weinger, MD; George T. Blike, MD; September 2003
An infant acutely desaturates following an ED nurse's premature administration of a paralytic medication.
Mary Caldwell, RN, PhD, MBA; Kathleen A. Dracup, RN, DNSc; September 2003
A patient given diltiazem rather than saline suffers severe bradycardia requiring temporary pacemaker.
Michael Cohen, RPh, MS, ScD (hon); April 2003
Antipsychotic, rather than antihistamine, mistakenly dispensed to woman with bipolar disorder with new urticaria.