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WebM&M: Case Studies

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.

Have you encountered medical errors or patient safety issues? Submit your case below to help the medical community and to prevent similar errors in the future.

This Month's WebM&Ms

Update Date: July 10, 2024
Have you encountered medical errors or patient safety issues?
Have you encountered medical errors or patient safety issues? Submit your case below to help the medical community and to prevent similar errors in the future.

All WebM&M: Case Studies (649)

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Displaying 1 - 20 of 651 Results
Displaying 1 - 20 of 651 Results

A 67-year-old man with severe low back pain was admitted to the hospital for anterior lumbar interbody fusion (ALIF) with bone autograft from the iliac crest. The surgical team had difficulty controlling bleeding and the patient left the operating room (OR) with the bone graft donor site open and oozing blood. In the postanesthesia care unit (PACU), the nurse called the attending physician three times to report hypotension and ongoing bleeding. Each time, the surgeon ordered hetastarch for volume expansion. Over the next 14 hours, the patient’s blood pressure remained at or below 90/60 with continued complaints of back and pelvic pain. The next morning, the patient was unresponsive and in severe hypovolemic shock. Electrocardiography confirmed a non-ST segment elevation myocardial infarction (NSTEMI). The patient was transferred to an intensive care unit and resuscitative efforts were initiated, but the patient expired from multiorgan failure resulting from hypovolemic shock. The commentary discusses appropriate management of ongoing intraoperative and postoperative bleeding and how a culture of safety can enable care team members to voice concerns about patient safety. 

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Christian Bohringer, MB BS and Gustavo Chavez, MD| July 10, 2024

A 36-year-old woman with class 2 obesity underwent a difficult laparoscopic hysterectomy, performed in the lithotomy position with a steep head down (Trendelenburg) position. Intermittent pneumatic compression devices were placed on both calves to prevent venous thrombosis (DVT), but on awakening from general anesthesia, the patient complained of severe pain in the right leg. The gynecologist made a presumptive diagnosis of DVT and put her on subcutaneous dalteparin at therapeutic dosing and acetaminophen and oral morphine for pain relief. The patient continued to complain of severe pain and paresthesias in her right calf and doppler ultrasound scan was negative for DVT. The next day the orthopedic on-call team was consulted and diagnosed compartment syndrome of the right leg. The patient required fasciectomy of the right leg and excision of necrotic muscle tissue, with a prolonged hospital stay. The commentary discusses how patient positioning during surgery can increase the risk for surgical complications, the role of interdisciplinary teamwork to achieve optimal positioning, and the importance of early identification of compartment syndrome to prevent permanent injury. 

Five weeks after gastric bypass surgery, a woman experienced persistent nausea and vomiting, leading to dehydration and multiple outpatient treatments. Despite visiting an outpatient clinic and emergency department (ED) for ongoing symptoms and significant weight loss, the nausea and vomiting persisted. Eventually, she was admitted to the ICU with pancreatitis and dehydration. Subsequently, she exhibited neurological symptoms including difficulty walking, tingling sensations, and cognitive impairment. She was discharged with orders for total parenteral nutrition (TPN). Three days after discharge, she was readmitted for worsening confusion and profound motor weakness, which progressed to respiratory failure requiring mechanical ventilation. Laboratory tests revealed an extremely low thiamine level, and the patient was diagnosed with advanced Wernicke-Korsakoff Syndrome, exacerbated by a lack of proper nutrition, and resulting in permanent brain damage, necessitating ongoing care. The commentary discusses how biases associated with medical conditions, such as obesity and its treatment, can lead to poorer outcomes, as well as strategies to continually re-evaluate diagnostic reasoning in light of ongoing, intensive management and management reasoning

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Elizabeth Gould, NP-C, CORLN, Krystal Craddock, BSRC, RRT, RRT-ACCS, RRT-NPS, AE-C, CCM, Tyler Le Tellier, RRT, Brooks T Kuhn, MD, MAS| May 29, 2024

A 55-year-old man with a history of osteoarthritis and supraventricular tachycardia was admitted the hospital with severe COVID-19 and required endotracheal intubation and invasive mechanical ventilation. Following transfer to a long-term care hospital (LTCH) for continued weaning from mechanical ventilation, inadequate tracheostomy management protocols were evident, with no specific instructions provided. Subsequently, the patient experienced respiratory distress and cardiac arrest due to a blocked tracheostomy tube, highlighting critical deficiencies in care and communication. The commentary summarizes the risk factors for tracheostomy complications, the importance of tracheostomy tube maintenance and monitoring, and strategies to safeguard tracheostomy tube care during transitions of care. 

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A 57-year-old man was rushed to the Emergency Department from a nursing facility, struggling to breathe. With a history of hypertension, diabetes, and heart failure, his vital signs were concerning, showing high blood pressure, rapid heart rate, and low oxygen levels. Examinations revealed fluid buildup in his lungs and legs, indicating severe heart and kidney problems. Despite attempts to remove excess fluid with medication, dialysis became necessary. However, a complication arose during catheter insertion, requiring emergency surgery to retrieve a misplaced guidewire.

Commentary by Vijay Agusala, MD, MBA, James Deen, MD and Saul Schaefer, MD| May 29, 2024

A man in his 70s with a past medical history of lymphoma in remission, obesity, hypertension, hyperlipidemia, obstructive sleep apnea, and supraventricular tachycardia presented to the emergency department (ED) after two weeks of nightly chest pain episodes. His primary care physician had ordered laboratory testing, which was unremarkable other than a slightly elevated D-dimer (which was normal when adjusted for age). His physical examination and laboratory tests in the ED were normal and he had a record of normal stress testing from two years prior. The patient was discharged from the ED the same day but passed away at home two days later due to severe coronary artery disease. The commentary discusses the varied presentation of unstable angina, use of appropriate evaluation and risk stratification, as well as organizational strategies to facilitate thorough patient evaluation across multiple providers, such as standardized patient handoff methods. 

Christian Bohringer, MBBS, Manuel Fierro, MD, and Sandhya Venugopal, MD | April 24, 2024

A 77-year-old man was admitted for coronary artery bypass graft surgery with aortic valve replacement. The operation went smoothly but the patient went into atrial fibrillation with hypotension during removal of the venous cannula. The patient was shocked at 10 Joules but did not convert to sinus rhythm; the surgeon requested 20 Joules synchronized cardioversion, after which the patient went into ventricular fibrillation and was immediately and successfully defibrillated with 20 Joules. While the patient was being transferred to his gurney, the operating room team noticed that the electrocardiogram cable that enables synchronized cardioversion was only connected into the anesthesia monitor and was never connected to the patient’s defibrillator. The commentary discusses the risks of unsynchronized shocks or pacing, the role of standardized processes to ensure that operating room equipment is prepared and set-up correctly, and the importance of operating room team preparation to urgently address life threatening complications

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Ron Ordona, DNP, FNP-BC, GS-C, WCC and Deb Bakerjian, PhD, APRN, FAANP, FGSA, FAAN | April 24, 2024

An elderly patient residing in a group care home, requiring assistance with all activities and having a history of autism-spectrum disorder, experiences fecal leakage issues despite daily medication. During a weekend shift with reduced staffing, a certified nursing assistant (CNA) discovers the patient soiled in bed, necessitating a shower. While attempting to assist the patient, another bowel accident occurs, leading to a fall and head injury when the CNA calls for help. With limited staff available, the patient is eventually taken to the hospital for suturing and further evaluation, where it's determined she requires a higher level of care due to hazardous conditions in the bathroom. The commentary discusses the challenges in providing adequate care in group home settings, especially during weekends with reduced staffing levels.

Catherine Mueller, PharmD, CPPS, Paul MacDowell, PharmD, BCPS, and James A. Bourgeois, OD, MD | April 24, 2024

A 26-year-old man presented to the emergency department (ED) with abdominal pain, displaying tachycardia and extreme agitation. Despite negative findings on physical examination and laboratory tests, his aggressive behavior escalated, necessitating physical and chemical restraint for the safety of both himself and ED staff. The ED physician verbally ordered 10 mg of intramuscular haloperidol, but the primary nurse overrode the automated dispensing unit and mistakenly pulled a vial of midazolam 10 mg instead of haloperidol. Flumazenil was subsequently administered to reverse benzodiazepine toxicity, and the patient recovered without further complications. The commentary discusses best practices to promote safe medication administration in the context of verbal orders and medication overrides.

David K. Barnes, MD, FACEP, Sahej Deep Singh Randhawa, MD, and Ellen P. Fitzpatrick, MD| April 24, 2024

This pair of cases highlight the immediate and long-term consequences of delayed recognition of compartment syndrome, despite patients presenting with symptoms such as severe pain, numbness, and swelling in the affected limbs. The commentary discusses the importance of a multifactor assessment when compartment syndrome is suspected, effective processes for trainees and non-physician staff to escalate concerns to attending physicians when compartment syndrome is suspected, and improving post-discharge follow-up practices to identify patients requiring further evaluation.

Anita Singh, MD and Cecilia Huang, MD | April 10, 2024

An 82-year-old woman presented to the emergency department for evaluation of “altered mental status” after falling down 5 step-stairs at home. She had a Glasgow Coma Score of 11 (indicating decreased alertness) on arrival. Computed tomography (CT) of the head revealed a right thalamic hemorrhage. She was admitted to the Vascular Neurology service. Overnight, the patient developed atrial fibrillation with rapid ventricular rate (RVR), which required medications for rate control. The patient failed her swallow evaluation by speech therapy; therefore, a nasogastric (NG) tube was inserted through her right nostril, without difficulty or complications, to administer oral medications. A chest radiograph was obtained to verify placement, but the resident physician did not review the images. During nursing shift change, the incoming nurse was told that the NG tube was ready for use. A tablet of metoprolol 25 mg was crushed by the nurse, mixed with water, and administered through the NG tube. A few minutes after administration, the patient was found to be somnolent and hypoxemic, with oxygen saturation around 80%, requiring supplemental oxygen via non-rebreather mask. Chest radiography showed that the NG tube was in the right lung. The commentary underscores the importance of confirming proper placement of NG tubes before administering feedings, fluids or medications and strategies to reduce the risk of tube placement errors.

Eric Signoff, MD, Noelle Boctor, MD, and David K. Barnes, MD, FACE| April 10, 2024

A 61-year-old patient presented to the emergency department (ED) complaining of weakness with findings of shuffling gait, slurred speech, delayed response to questions, and inability to concentrate or make eye contact. A stroke alert was activated and a neurosurgeon evaluated the patient via teleconsult. There was no intracranial hemorrhage identified on non-contrast computed tomography (CT) of the head and the neurosurgeon recommended administering Tenecteplase (TNKase). Thirty minutes after TNKase administration, laboratory tests showed that the patient’s alcohol level was 433 mg/dL, a potentially fatal level. The patient was admitted to the intensive care unit (ICU) for close monitoring. A repeat CT scan was performed and revealed a new subdural hemorrhage. The neurosurgeon was updated, conservative treatment was recommended, and the patient recovered slowly. The commentary highlights how “stroke chameleons,” “stroke mimics,” and biases contribute to stroke misdiagnosis and strategies to identify “stroke mimics” and improve stroke diagnosis.

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Michelle Hamline, MD, PhD, MAS and Ulfat Shaikh, MD, MPH| March 27, 2024

A five-year-old girl presented to the emergency department (ED) with symptoms of an upper respiratory tract infection. A viral swab was negative for SARS-CoV2, influenza, and respiratory syncytial virus. A throat swab was positive for group A Streptococcus. The patient returned the next day with worsening symptoms but the treating physician again did not order imaging and attributed all findings to pharyngitis. The child was sent home with a prescription for amoxicillin. On day 3 after the first ED visit, the child was brought back to the ED by ambulance with pulseless electrical activity at a heart rate of 70 bpm and oxygen saturation of 40% with no spontaneous respirations. On examination during resuscitation, there was skin mottling and petechiae. She was pronounced dead after resuscitative efforts failed. Autopsy showed bilateral pneumonia and right-sided empyema. Empyema cultures grew Streptococcus pyogenes and Klebsiella pneumoniae. The commentary discusses the importance of timely recognition and proper management of potential bacterial infections to prevent downstream morbidity and mortality from sepsis.

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A patient who was 39-weeks pregnant presented to the hospital in active labor, admitted to the Labor and Delivery unit and confirmed to have a full-term singleton fetus in vertex presentation. After several hours on oxytocin, the fetal head was still relatively high and the fetal heart rhythm suggested hypoxemia. The physician attempted delivery using a vacuum, but ultimately performed an emergency cesarean delivery of a healthy newborn. The procedure was complicated by the need to extend the lower uterine segment incision bilaterally for safe extraction of the fetus. The operator’s note described post-delivery repair of the right uterine incision but did not comment on the left side. Following the delivery, the patient was noted to be hypotensive and tachycardic and went into cardiac arrest. Another physician opened the patient’s incision and found nearly three liters of blood had collected in her abdomen, apparently due to complete transection of the left uterine artery. The commentary highlights the risk factors for obstetric hemorrhage, summarizes standardized risk assessments used to alert for potential obstetric hemorrhage and use of obstetric simulation training to improve team communication and performance.

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James A. Bourgeois, OD, MD and Glen Xiong, MD | March 27, 2024

An 18-year-old woman with no significant past medical history was admitted to a community hospital for evaluation and treatment of acute psychosis with paranoid delusions and started on an antipsychotic medication. On hospital day 7, the nurse practitioner learned from the patient’s father that there was a family history of systemic lupus erythematosus (SLE) and suggested that the patient be evaluated for lupus. Laboratory tests indicated borderline pancytopenia, an elevated antinuclear antibody (ANA), and abnormally elevated anti-double-stranded DNA, but these laboratory tests were not evaluated until 2-3 days after discharge and the patient was never referred for further evaluation. The commentary discusses the clinical manifestations of a primarily psychiatric presentation of SLE, the importance of family history when evaluating patients with psychotic presentations, and the need for clear communication between medical specialists to ensure safe, high-quality care.

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Karl Steinberg, MD, CMD, HMDC, HEC-C| March 27, 2024

A 76-year-old was readmitted for altered mental status after a recent hospitalization. He was experiencing hypoxia and required supplemental oxygen but was intermittently combative, repeatedly asked to go home and declined most medical interventions. His family, who lived a few hours away, acted as his medical decision-makers but were not able to travel to the hospital to see him. A treating clinician documented a discussion where the patient agreed to hospice enrollment however the palliative medicine consultant determined that he did not have capacity to make decisions due to delirium, nor was he clearly eligible for hospice. The care team and the patient’s family decided to continue to treat the patient’s underlying medical issues and to wait to see if his delirium improved. In subsequent days, the patient's mental status improved, and he was able to express opposition to hospice care. He was then transferred to a skilled nursing facility near his family for rehabilitation. The commentary discusses the importance of prompt identification and treatment of delirium, the role of shared decision-making with patients and their caregivers, and how clinicians should assess and address decisional capacity

A 60-year-old woman with a history of cirrhosis arrived at the emergency department (ED) with an open right ankle injury and moderate blood loss after falling at home. A tourniquet was placed and her initial point-of-care hemoglobin was 7 mg/dl, so a “massive transfusion protocol” was initiated. The patient progressed to cardiac arrest and chest tubes were placed on both sides of the chest. After return of spontaneous circulation, fluid was identified in the abdomen, so the patient was immediately transferred to the operating room (OR) for exploratory laparotomy. Bleeding was noted to be coming from lacerations in the lateral chest wall and in the right lateral aspect of the liver, which was enlarged and visibly cirrhotic with splenomegaly. Multiple packing maneuvers were attempted but definitive hemorrhage control could not be obtained. This commentary highlights the challenges in managing blunt trauma in actively bleeding patients with a history of cirrhosis and the importance of frameworks and protocols (e.g., Advanced Trauma Life Support [ATLS], Massive Transfusion Protocol [MTP]) to protect against misadventures in the trauma bay.

Timothy Do, BS and Fiona J Scott, MD, MPH, MS, MHI| February 28, 2024

A 32-year-old woman was admitted to the hospital for endoscopic retrograde cholangiopancreatography (ERCP) under monitored anesthesia care (MAC). As the endoscope was advanced into the stomach, the patient vomited. She was immediately turned supine but copious vomitus obstructed the suction catheter. The patient started to decompensate with decreasing oxygen saturation. The anesthesia team attempted to secure the airway by endotracheal intubation but was unable to place a tube due to poor view and vomitus. The patient went into cardiac arrest and ultimately passed away. The commentary discusses safety considerations for ERCP under MAC, weighing the risks and benefits of MAC versus general anesthesia, and airway management during emergencies.

Christian Bohringer, MBBS and Linda Vo, MD| February 28, 2024

A 47-year-old obese man with hypertension fell and suffered a cervical spine (C5/C6) fracture. He was scheduled for urgent anterior cervical decompression and fusion and was transferred to the operating room (OR) where general anesthesia was induced. During the procedure, his expired tidal volume decreased from 560 ml to about 330 ml. He was manually ventilated through the endotracheal tube, which proved very difficult. An urgent chest X-ray did not reveal any pneumothorax. The Black Belt cervical retractor was released by the surgeon resulting in complete resolution of the airway obstruction. The commentary highlights the importance of vigilant monitoring and good communication to identify and respond to life-threatening events and describes approaches to improve crisis management during anesthesia events.

Jazmin A. Wander, MD and David K. Barnes, MD, FACEP.| January 31, 2024

A woman presented to the emergency department (ED) for evaluation of a laceration to the palmer aspect of her left thumb. The treating clinician documented a superficial 3cm laceration and that the patient was unable to flex her thumb due to pain. The clinician closed the laceration with sutures. Neither a sensory examination nor wound exploration was documented. No fracture or foreign body was identified on x-ray but the procedure note did not mention whether the tendon was visualized. Several weeks after discharge from the ED, the patient was still unable to flex her thumb and was referred to an orthopedic surgeon and a hand specialist who surgically repaired a laceration to the flexor tendon. The commentary discusses the importance of including neurovascular and functional testing when evaluating hand injuries and the role of diagnostic imaging as well as strategies to improve diagnosis and mitigate human error when treating hand injuries.

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