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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: October 31, 2023
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 (11)
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Displaying 1 - 11 of 11 Results
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    • Which Line: Ordering Provider or Proceduralist?
    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.
    Consequences of Medical Overuse
    Daniel J. Morgan, MD, MS, and Andrew Foy, MD| March 1, 2017
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    • Brought to the emergency department from a nursing facility with confusion and generalized weakness, an older woman was found to have an elevated troponin level but no evidence of ischemia on her ECG. A consulting cardiologist recommended treating the patient with three anticoagulants. The next evening, she became acutely confused and a CT scan revealed a large intraparenchymal hemorrhage with a midline shift.
    Total Parenteral Nutrition, Multifarious Errors
    Joseph I. Boullata, PharmD, RPh, BCNSP| April 1, 2013
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    • A 3-year-old boy hospitalized with anemia who was on chronic total parenteral nutrition was given an admixture with a level of sodium 10-fold higher than intended. Despite numerous warnings and checks along the way, the error still reached the patient.
    The Forgotten Turn
    Susan Barbour, RN, MS, FNP| December 1, 2010
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    • Admitted to the hospital with right-hip and left-arm fractures, an elderly woman remained on the same bed from the emergency department for nearly 16 hours and developed a moderate-sized, stage 2 pressure ulcer.
    Recurrent Hypoglycemia: A Care Transition Failure?
    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.
    Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad
    Sumant Ranji, MD| April 1, 2008
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    • A woman with symptoms of sinusitis was given 2 different courses of broad-spectrum antibiotics, neither of which improved her symptoms. Hospitalized for autoimmune hemolysis (presumably from the antibiotic), the patient suffered multiorgan failure and septic shock, and died.
    Right? Left? Neither!
    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.
    The Wet Read
    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.
    An Ounce of Prevention
    Nils Kucher, MD| January 1, 2006
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    • Following reconstructive surgery to her hand, a woman suffers sudden cardiopulmonary arrest. After successful resuscitation, further review revealed that she had a pulmonary embolism and that she had received no venous thromboembolism prophylaxis.
    Too Tight Control
    Haya R. Rubin, MD, PhD; Vera T. Fajtova, MD| May 1, 2004
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    • To achieve tight glucose control, a hospitalized diabetes patient is placed on an insulin drip. Prior to minor surgery, he is made NPO and becomes severely hypoglycemic.
    Crossing the Line
    Jeremy P. Feldman, MD; Michael K. Gould, MD, MS | March 1, 2004
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    • A central line placed incorrectly causes a patient to suffer permanent neurologic damage.
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