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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: April 10, 2024
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,... Read More

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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 (641)

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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 (TNK). Thirty minutes after TNK 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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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.

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

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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Kimberly Beres, DNAP, MHS, CRNA and Maria Cristina Gutierrez, MD | January 31, 2024

A patient presented for open reduction and internal fixation of a fractured radius under an ultrasound-guided supraclavicular brachial plexus nerve block. The initial attempt at local anesthesia using 2% lidocaine was inadequate, necessitating a subsequent lidocaine injection, followed by the procedural block using 20 ml of 0.375% plain bupivacaine. The patient developed progressive dyspnea and diminishing oxygen saturation, prompting emergent intubation and initiation of mechanical ventilation. The respiratory distress was traced back to an inadvertent injection of vecuronium (a neuromuscular blocking agent) instead of the intended local anesthetic during the initial attempt at brachial plexus nerve block. The commentary outlines approaches to improving perioperative safety, including the importance of safety culture, improving medication labeling and packaging, and using medication checks, checklists, and handoffs to reinforce professional provider responsibilities.

Jihey Yuk, MD and Julia Magana, MD | January 4, 2024

A 2-month-old boy was brought to the pediatric emergency department (PED) with a non-specific clinical picture of decreased responsiveness in the setting of a viral upper respiratory illness (URI) and appeared somnolent on initial evaluation. His pulmonary, cardiac, and abdominal examinations were unremarkable. He had normal muscle tone and movement of extremities and no bruising or abrasions were noted. Due to his persistently altered mental status, ultrafast magnetic resonance imaging (MRI) of the brain was obtained. Given limited overnight staffing, the MRI images were preliminarily read by a radiology resident. The patient was discharged with a parent after an “unremarkable” preliminary interpretation of the MRI. However, the next morning, the final reading of the MRI by the attending physician noted a small (5mm) subdural hemorrhage. The family was called back to the PED for further evaluation and a parent disclosed that the child had fallen off a bouncy seat placed on the bed, onto the floor, 3 days prior to presentation. The commentary discusses the pitfalls that clinicians encounter when they consider child abuse in the differential diagnosis and approaches to identifying non-accidental trauma (NAT) in pediatric patients.

A 9-year-old girl with cerebral palsy and epilepsy presented to the emergency department (ED) for increasing frequency of seizures lasting about 5 minutes, and developed hypoxic respiratory failure requiring endotracheal intubation, sedation, and mechanical ventilation. The pediatric neurology team ordered further testing, most of which had to be sent to an external laboratory and the results returned intermittently over several weeks. Several days into the hospital stay, acetylcholine receptor antibody test results returned markedly elevated at 302 nmol/L (normal is <0.5 nmol/L), which is concerning for myasthenia gravis. The laboratory finding that established this diagnosis was available in the electronic health record (EHR), but it was invisible to multiple teams of providers across multiple phases of care due to issues related to the EHR itself, challenges in clinical reasoning, and the workflow around transitions of care. The commentary highlights strategies to improve EHR systems to prevent diagnostic delays and care coordination for children with complex, chronic medical conditions

Berit Bagley, RN, MSN, CDCES, BC-ADM, Charity L. Tan, MSN, ACNP-BC, CDCES, BC-ADM, Deborah Plante, MD | November 30, 2023

A 67-year-old man with well-controlled type 2 diabetes mellitus underwent elective cardiac resynchronization and defibrillator device (CRT-D) implantation. The procedure was successful and he was discharged the next day with instructions to resume his prior medications, including empagliflozin. He presented to the emergency department the following day where he was diagnosed with euglycemic diabetic ketoacidosis (eDKA) and he was transferred to the intensive care unit (ICU) for insulin infusion. On further questioning, it was discovered that the patient had not been instructed to stop taking his empagliflozin three days before his elective cardiology procedure. He was told only to hold it on the day of the procedure, and to resume all medications after discharge; he carefully followed these instructions. 

Luciano Sanchez, PharmD and Patrick Romano, MD, MPH| November 30, 2023

An 81-year-old man was admitted to the intensive care unit (ICU) with a gastrointestinal bleed and referred for a diagnostic colonoscopy. The nurse preparing the patient for the colonoscopy mistakenly selected a jug of dialysis liquid rather than a polyethylene glycol solution commonly used to clean the colon for colonoscopy. When the barcode on the jug of dialysis liquid did not scan, the nurse called the hospital pharmacy for assistance and was provided a new barcode via a tube system. After the patient had difficulty drinking the solution, the nurse gave the rest of the liquid through a feeding tube bag. The medication mix-up was identified around midnight and the patient died about 7 hours later. 

Christian Bohringer, MBBS, and Sharon Ashley, MD | November 30, 2023

A 38-year-old woman with class 3 obesity required removed of a gastric balloon under general anesthesia. She required a relatively large dose of rocuronium for endotracheal intubation, and she was given intravenous sugammadex (200 mg) at the end of the procedure to reverse the neuromuscular block. A quantitative neuromuscular block monitor was not used, but reliance was placed on clinical signs. Shortly after arrival in the post-anesthesia care unit, she couldn’t move or open her eyes and became jittery with low oxygen saturation. Quantitative blockade monitoring revealed a “train of four” (TOF) ratio less than 70%, so she was given another 200 mg of intravenous sugammadex with return of normal motor function.

Rachel Ann Hight, MD, FACS | November 29, 2023

This case describes a 55-year-old woman who sustained critical injuries after a motor vehicle crash and had a lengthy hospitalization. On hospital day 30, a surgeon placed a percutaneous endoscopic gastrostomy (PEG) tube in the intensive care unit (ICU) after computed tomography (CT) scan showed no interposed bowel between the stomach and the anterior abdominal wall.  After the uncomplicated PEG placement, the surgeon cleared the patient’s team to advance tube feeds as tolerated. After several weeks of poorly tolerated tube feedings, the interventional radiology team reviewed a CT scan which had been obtained by another service 6 days after the PEG was placed and noted (for the first time) that the gastrostomy tube traversed the liver. Insufficient communication and fragmented care coordination across care settings contributed to poor management of the malpositioned PEG tube. The commentary underscores the importance of clear documentation of complications, highlights best practices to mitigate risks during patient care transition, and the importance of using multiple communication approaches to ensure appropriate continuity of care.

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Nidhi Patel Jain, PharmD, MBAc and David Dakwa, PharmD, MBA, BCPS, BCSCP | October 31, 2023

A 2-year-old girl presented to the emergency department (ED) with joint swelling and rash following an upper respiratory infection. After receiving treatment and being discharged with a diagnosis of allergic urticaria, she returned the following day with worsening symptoms. Suspecting an allergic reaction to amoxicillin, the ED team prepared to administer methylprednisolone. However, the ED intake technician erroneously switched the patient’s height and weight in the electronic health record (EHR), resulting in an excessive dose being ordered and dispensed. An automatic error message was generated due to the substantial difference from previous weights, but this message was overlooked by the ED technician and the data entry error was not detected or corrected. The commentary discusses the importance of verifying medication orders before administration, optimizing alert notifications to minimize the risk of alert fatigue, and the role of root cause analysis to identify factors contributing to medication error

Hang Mieu Ha, DO and Kristin Alexis Olson, MD| October 31, 2023

A 32-year-old man presented to the hospital with a comminuted midshaft femoral fracture after a bicycle accident. Imaging suggested the fracture was pathologic and an open biopsy specimen was submitted to pathology for intraoperative consultation. However, this procedure was followed by a series of events that increased the likelihood for harm, including the inability to provide a definitive diagnosis at the time of frozen section examination, the subsequent delayed diagnosis, lack of cross coverage for leave among care team members, and poor communication and handoffs.

This WebM&M describes two cases illustrating several types of Electronic Health Record (EHR) errors, with a common thread of erroneous use of electronic text-generation functionality, such as copy/paste, copy forward, and automatically pulling information from other electronic sources to populate clinical notes. The commentary discusses other EHR-based documentation tools (such as dot phrases), the influence of new documentation guidelines, and the role of artificial intelligence (AI) tools to capture documentation.