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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 26, 2023
Spotlight Case
CE/MOC
Commentary by Michael Leonardo Amashta, MD, and David K. Barnes, MD, FACEP
| April 26, 2023
This case involves a procedural sedation error in a 3-year-old patient who presented to the... Read More
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Barbara Resnick, PhD, CRNP, and Marie Boltz, PhD, CRNP | April 26, 2023
This Spotlight Case highlights two cases of falls in older patients in nursing homes. The commentary discusses how risk factors... Read More
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Charleen Singh, PhD, MSN/ED, FNP-BC, CWOCN, RN and Brent Luu, PharmD, BCACP
| April 26, 2023
This case represents a known but generally preventable complication of calcium chloride infusion, eventually necessitating surgical... Read More
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 (23)
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Garima Agrawal, MD, MPH, and Mithu Molla, MD, MBA
|
May 16, 2022
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This WebM&M describes two cases involving patients who became unresponsive in unconventional locations – inside of a computed tomography (CT) scanner and at an outpatient transplant clinic – and strategies to ensure that all healthcare teams are prepared to deliver advanced cardiac life support (ACLS), such as the use of mock codes and standardized ACLS algorithms.
Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP|
May 27, 2020
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A patient with multiple comorbidities and chronic pain was admitted for elective spinal decompression and fusion. The patient was placed on a postoperative patient-controlled analgesia (PCA) for pain control and was later found unresponsive. The case illustrates risks associated with opioid administration through PCA, particularly among patients at high risk for postoperative opioid-induced respiratory depression.
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.
Elise Orvedal Leiten, MD, and Rune Nielsen, MD, PhD|
January 1, 2019
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Hospitalized in the ICU with hypoxic respiratory failure due to community-acquired pneumonia, an elderly man had increased pulmonary secretions on hospital day 2 for which the critical care provider decided to perform bedside bronchoscopy. Following the procedure, the patient was difficult to arouse, nearly apneic, and required intubation. The care team paused and discovered that after the patient had received 2 mg of intravenous midalozam, his IV line had been flushed with an additional 10 mg of the benzodiazepine, rather than the intended normal saline. This high dose of midazolam led to the respiratory failure requiring intubation. On top of that, instead of normal saline, lidocaine had been used for the lung lavage.
Rodney W. Hicks, PhD, RN, FNP|
February 1, 2013
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After delivering a healthy infant via Caesarean section, a young woman was to receive morphine via PCA pump. A mix-up in programming the concentration of medication delivered by the pump led to a fatal outcome.
Debora Simmons, PhD, RN|
September 1, 2011
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Following surgery, a cancer patient was receiving total parenteral nutrition and lipids through a central venous catheter and pain control through an epidural catheter. A nurse mistakenly connected a new bottle of lipids to the epidural tubing rather than the central line, and the error was not noticed for several hours.
Amy A. Vogelsmeier, PhD, RN|
September 1, 2011
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Following surgical repair for a hip fracture, a nursing home resident with limited mobility developed a fever. She was readmitted to the hospital, where examination revealed a very deep pressure ulcer. Despite maximal efforts, the patient developed septic shock and died.
Edward A. Bittner, MD, PhD|
February 1, 2011
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Following elective anterior cervical discectomy, a patient developed tightness and swelling in his neck. Later, the patient stood up, turned blue, and fell to the floor unconscious. An obvious neck hematoma was compromising his airway, and the patient required an emergency tracheostomy and CPR.
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.
Victoria Rich, PhD, RN|
August 1, 2009
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Admitted to the ICU for COPD exacerbation and atrial fibrillation, a patient who had stabilized is left unattended in the bathroom while the nurse on an understaffed unit attends to a more emergent patient. An assistant later finds the patient on the floor, unresponsive and cyanotic.
Norma A. Metheny, RN, PhD; Kathleen L. Meert, MD|
September 1, 2008
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A boy was receiving enteral feedings while recovering from a traumatic brain injury. The nasojejunal tube migrated to the gastric area, and the patient developed pneumonia, likely due to aspiration.
Lisa Schulmeister, RN, MN, APRN-BC|
January 1, 2008
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A nurse has trouble placing an IV catheter for a woman receiving her first dose of outpatient chemotherapy. The patient complains of pain at the site. Closer examination revealed that the chemotherapy had infused outside of the vein into the skin.
Heather Cleland, MBBS; Jason Wasiak, BN, MPH|
December 1, 2007
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After removing the IV line on an infant receiving IV fluid and antibiotics, a nurse places a warm compress on the wound site. Later, another nurse discovers that the compress has caused a burn.
Elizabeth A. Henneman, RN, PhD|
May 1, 2007
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A young woman with Takayasu's arteritis, a vascular condition that can cause BP differences in each arm, was mistakenly placed on a powerful intravenous vasopressor because of a spurious low BP reading. The medication could have led to serious complications.
Mary A. Blegen, PhD, RN; Ginette A. Pepper, PhD, RN|
May 1, 2006
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A nursing student administers the wrong 'cup' of medications to an elderly man. A different student discovered the error when she reviewed the medicines in her patient's cup and noticed they were the wrong ones.
Douglas D. Brunette, MD|
March 1, 2005
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The challenges of examining and imaging a hospitalized morbidly obese patient delay diagnosis, threatening the patient's life.
Ann Williamson, PhD, RN|
May 1, 2004
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An antenatal room left in disarray causes a charge nurse to search for the missing patient. Investigation reveals that a resident had performed an ultrasound on a nurse friend rather than a true "patient."
Darren R. Linkin, MD; Ebbing Lautenbach, MD, MPH, MSCE|
February 1, 2004
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Infection Control notices an uptick in post-operative wound infections for patients from one OR team. Environmental rounds reveal "sloppy" practices.
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.
Robert S. Wigton, MD|
October 1, 2003
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Misplacement of an NG tube sends charcoal into the lung; the patient dies of complications.
