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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: August 30, 2023
Sarah Marshall, MD and Nina M. Boe, MD | August 30, 2023
A 31-year-old pregnant patient with type 1 diabetes on an insulin pump was hospitalized for euglycemic diabetic ketoacidosis (DKA). She... Read More
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By Christian Bohringer, MBBS, and Ryan Osborne, MD | August 30, 2023
This case describes a 27-year-old primigravid woman who requested neuraxial anesthesia during induction of labor. The... 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 (14)
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Glen Xiong, MD and Debra Kahn, MD|
November 27, 2019
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Two different patients were seen in the emergency department a history of excessive alcohol consumption and suicidal ideation along with other medical comorbidities. In both cases, acute medical conditions prevented a comprehensive psychiatric evaluation being completed by psychiatric emergency services. Unfortunately, both patients were discharged after resolution of their medical conditions and were later found dead.
Isla M. Hains, PhD|
June 1, 2012
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An elderly woman was transferred to a tertiary hospital for surgical repair of hip fracture, without complete information or records. The receiving surgeons were not informed that she had a cardiac arrest during induction of anesthesia at the community hospital. Surgery proceeded, but the patient died a few days later.
Albert Wu, MD, MPH|
November 1, 2011
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An elderly man discharged from the emergency department with syringes of anticoagulant for home use mistakenly picked up a syringe of atropine left by his bedside. At home the next day, he attempted to inject the atropine, but luckily was not harmed.
Jim Smith, PT, DPT, MA|
October 1, 2011
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Admitted to the trauma service following severe injuries, a man is transferred to the ICU for mechanical ventilation. After 6 weeks of hospitalization, the patient's initial shoulder injury progressed to involve significantly limited mobility and pain, prompting concern that physical therapy should have been initiated earlier.
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.
Margaret Fang, MD, MPH; Raman Khanna, MD, MAS|
July 1, 2011
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Following hospitalization for community-acquired pneumonia, an elderly man with a history of dementia, falls, and atrial fibrillation is discharged on antibiotics but no changes to his anticoagulation medication. One week later, the patient’s INR was dangerously high.
Emily S. Patterson, PhD|
November 1, 2008
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Due to lack of communication during shift change, an infant's transfer to a higher level of care is delayed. The infant develops respiratory distress, prompting a call to the rapid response team and transfer to the ICU.
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.
Hildy Schell, RN, MS, CCNS; Robert M. Wachter, MD|
July 1, 2006
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An elderly woman was transported to CT with no medical escort and an inadequate oxygen supply. She died later that day.
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.
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.
James G. Adams, MD|
June 1, 2003
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Abdominal pain misdiagnosed in an ED patient leads to ruptured appendix, multiple complications, and prolonged hospitalization.
