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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: November 30, 2023
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... Read More
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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.... Read More
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... Read More
Rachel Ann Hight, MD
| November 29, 2023
This case describes a 55-year-old woman who sustained critical injuries after a motor vehicle crash and had a lengthy... Read More
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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 (22)
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Nicole M. Acquisto, PharmD, and Daniel J. Cobaugh, PharmD|
March 1, 2019
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Seen in the emergency department, a man with insulin-dependent diabetes mellitus had not taken insulin for 3 days. His blood glucose levels were in the 800s with an anion-gap acidosis and positive beta hydroxybutyrate. While awaiting an ICU bed for treatment of diabetic ketoacidosis, the patient received fluids, an insulin drip was started, and blood glucose levels were monitored hourly. When lab results showed he was improving, the team decided to convert his insulin drip to subcutaneous long-acting insulin. However, both the intern and the resident ordered 50 units of insulin, and the patient received both doses—causing his blood glucose level to dip into the 30s.
C. Craig Blackmore, MD, MPH|
March 1, 2019
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A woman with multiple myeloma required placement of a central venous catheter for apheresis. The outpatient oncologist intended to order a nontunneled catheter via computerized provider order entry but accidentally ordered a tunneled catheter. The interventional radiologist thought the order was unusual but didn't contact the oncologist. A tunneled catheter was placed without complications. When the patient presented for apheresis, providers recognized the wrong catheter had been placed, and the patient underwent an additional procedure.
Brian Clay, MD|
January 1, 2019
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Following urgent catheter-directed thrombolysis to relieve acute limb ischemia caused by thrombosis of her left superficial femoral artery, an elderly woman was admitted to the ICU. While ordering a heparin drip, the resident was unaware that the EHR order set had undergone significant changes and inadvertently ordered too low a heparin dose. Although the pharmacist and bedside nurse noticed the low dose, they assumed the resident selected the dose purposefully. Because the patient was inadequately anticoagulated, she developed extensive thrombosis associated with the catheter and sheath site, requiring surgical intervention for critical limb ischemia (including amputation of the contralateral leg above the knee).
Shareen El-Ibiary, PharmD, BCPS|
November 1, 2008
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A pregnant woman with asthma was admitted to the hospital with respiratory distress. Although the emergency department providers noted that she was pregnant, this information was not conveyed to the floor. On admission, the patient was given an antibiotic that could have been dangerous.
Ted Eytan, MD, MS, MPH|
October 1, 2008
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An elderly, non–English-speaking man with diabetes was admitted to the hospital twice in 8 days due to hypoglycemia. At discharge, the patient was instructed not to take any antidiabetic medications. In between hospitalizations, he saw his primary care physician, who restarted an antidiabetic medication.
F. Daniel Duffy, MD; Christine K. Cassel, MD|
October 1, 2007
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Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.
George R. Thompson III, MD, and Abraham Verghese, MD|
August 1, 2006
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A man with paraplegia was admitted to the hospital, but the admitting physician, night float resident, and daytime team all "deferred" examination of the genital area. The patient was later discovered to have life-threatening necrotizing fasciitis of this area.
Saul N. Weingart, MD, PhD|
August 1, 2006
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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.
Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD, MPP, MPH|
May 1, 2006
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A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.
Glenn Flores, MD|
April 1, 2006
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With no one to interpret for them and pharmacy instructions printed only in English, nonEnglish-speaking parents give their child a 12.5-fold overdose of a medication.
Ronald L. Arenson, MD|
March 1, 2006
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A patient with metastatic cancer admitted for pain control develops acute shortness of breath. The overnight resident reads the CT as a large pulmonary embolism, but the next morning, the attending reads it differently.
Dean Schillinger, MD|
March 1, 2004
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A misunderstanding of instructions on how to administer medication leads to an infant choking on a syringe cap.
Jeanne Mandelblatt, MD, MPH|
February 1, 2004
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A physician who does not accept Medicaid turns away a woman needing evaluation for 2 years of profuse vaginal bleeding. She later presents to the ED, where examination reveals invasive cervical cancer.
Donna L. Washington, MD, MPH|
January 1, 2004
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A triage nurse instructed by a physician to immediately bring a febrile child, who was possibly dehydrated, to the treatment area is stopped by the charge nurse, citing overcrowding. The parents seek treatment elsewhere; upon arrival, the child is in full arrest.
Tejal K. Gandhi, MD, MPH|
October 1, 2003
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Switched urine specimens lead to a patient receiving the wrong answer about her pregnancy test.
Charles Vincent, PhD|
October 1, 2003
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Trusting his memory more than the chart, a surgeon directs a resident to remove the wrong side on a patient with unilateral vulvar cancer.
Robert M. Wachter, MD|
October 1, 2003
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A missing lab result leads to a 6-month delay in informing a patient about a new diagnosis of HIV.
Mary Caldwell, RN, PhD, MBA; Kathleen A. Dracup, RN, DNSc|
September 1, 2003
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A patient given diltiazem rather than saline suffers severe bradycardia requiring temporary pacemaker.
Marilynn M. Rosenthal, PhD|
July 1, 2003
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An anxious patient awaiting ambulatory surgery is mistakenly put on the wrong operating table.
Lee A. Learman, MD, PhD|
June 1, 2003
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A woman was told she miscarried, even though she was still pregnant.
