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
This case involves a procedural sedation error in a 3-year-old patient who presented to the... Read More
This Spotlight Case highlights two cases of falls in older patients in nursing homes. The commentary discusses how risk factors... Read More
This case represents a known but generally preventable complication of calcium chloride infusion, eventually necessitating surgical... Read More
All WebM&M: Case Studies (10)
- Clear filter(35)
- Communication Improvement(10)
- Quality Improvement Strategies(10)
- Education and Training(3)
- Culture of Safety(2)
- Human Factors Engineering(2)
- Specialization of Care(2)
- Computerized Decision Support(1)
- Error Reporting and Analysis(1)
- Legal and Policy Approaches(1)
- Technologic Approaches(1)
This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services. During follow-up several days after discharge, the patient’s primary care provider noted that the PICC dressing was due to be changed and needed to be flushed, but the outpatient setting lacked the necessary supplies. An urgent referral to home health was placed, but the agency would be unable to attend to the patient for several days. The primary care provider changed the dressing, and the patient was referred to the emergency department for assessment. The commentary summarizes the risks of PICC lines, the role of infection prevention practices during the insertion and care of PICC lines, and the importance of patient education and skill assessment prior to discharge home with a PICC line.