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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: February 1, 2023
Craig Keenan, MD, Scott MacDonald, MD, Ashley Takeshita, and Dale Sapell, PharmD | February 1, 2023

A 38-year-old man with end-stage renal disease (ESRD) on chronic hemodialysis was admitted for nonhealing, infected lower leg wounds and underwent a below-knee amputation. He suffered from postoperative pain at the operative stump and was treated for... Read More

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Elizabeth Partridge, MD, MPH, Daniel Dodson, MD, MS, Mary Reilly, MHA, BSN, RN, CIC and Stuart H. Cohen, MD | February 1, 2023

A 5-day old male infant was admitted to the pediatric intensive care unit (PICU) and underwent surgery to correct a congenital heart defect. The patient’s postoperative course was complicated Staphylococcus aureus bacteremia and other problems,... Read More

Dahlia Zuidema, PharmD, Berit Bagley, MSN, and Charity L Tan MSN | February 1, 2023

This WebM&M highlights two cases of hospital-acquired diabetic ketoacidosis (DKA) in patients with type 1 diabetes. The commentary discusses the role of the inpatient glycemic team to assist with diabetes management, the importance of medication... Read More

Nicole A. Weiss, MD | February 1, 2023

A 27-year-old pregnant woman was diagnosed with severe pulmonary arterial hypertension at 29 weeks estimated gestational age (EGA) and admitted for elective cesarean delivery with lumbar epidural anesthesia at 36 weeks EGA. After epidural catheter... 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 (82)

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Displaying 1 - 20 of 82 WebM&M Case Studies
Carla S. Martin, MSN, RN, CIC, CNL, NEA-BC, FACHE, Shannon K. Reese, BSN, RN, VABC, and Margaret Brown-McManus, MSN, RN, CNL | September 28, 2022

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.

Garima Agrawal, MD, MPH, and Mithu Molla, MD, MBA | May 16, 2022

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.

Gary S. Leiserowitz, MD, MS and Herman Hedriana, MD| July 29, 2020

A 28-year-old woman arrived at the Emergency Department (ED) with back pain, bloody vaginal discharge, and reported she had had a positive home pregnancy test but had not received any prenatal care and was unsure of her expected due date. The ED intern evaluating the patient did not suspect active labor and the radiologist remotely reviewing the pelvic ultrasound mistakenly identified the fetal head as a “pelvic mass.” Four hours later, the consulting OB/GYN physician recognized that the patient was in her third trimester and in active labor. She was transferred to Labor and Delivery for labor management, which led to an emergency cesarean section. A neonatal seizure was observed, and brain MRI revealed a perinatal stroke. The Commentary discusses the types of diagnostic errors leading to missed diagnoses and the importance of appropriate supervision of physician trainees.

Zara Cooper, MD, MSc| September 25, 2019
A man with a history of T6 paraplegia came to the emergency department with delirium, hypotension, and fever. Laboratory results revealed a high white blood cell count and mild elevation of bilirubin and liver enzymes. A stat abdominal CT showed a mildly thickened gallbladder. The patient was admitted to the intensive care unit with a provisional diagnosis of septic shock and treated with broad-spectrum antibiotics and intravenous fluids. He was transferred to the medical ward on hospital day 2, where the receiving hospitalist realized the diagnosis was still unclear. A second CT scan showed a 6 cm abscess near the liver, likely arising from a perforated gallbladder. The patient underwent an urgent open cholecystectomy and drainage of the abscess.
Stephanie Rogers, MD, and Derek Ward, MD| April 1, 2019
An elderly man with a complicated medical history slipped on a rug at home, fell, and injured his hip. Emergency department evaluation and imaging revealed no head injury and a left intertrochanteric hip fracture. Although he was admitted to the orthopedic surgery service, with surgery to fix the fracture initially scheduled for the next day, the operation was delayed by 3 days due to several emergent trauma cases and lack of surgeon availability. He ultimately underwent surgery and was discharged a few days later but was readmitted several weeks later with chest pain and shortness of breath. He was found to have a pulmonary embolism; anticoagulation was initiated. The patient's rehabilitation was delayed, his recovery was prolonged, and he never returned to his baseline functional status.
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).
Elise Orvedal Leiten, MD, and Rune Nielsen, MD, PhD| January 1, 2019
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.
A 1-month-old preterm infant in the NICU receiving the standard 500 mL bag of 0.45% sodium chloride (NaCl) with heparin at low rates developed hyponatremia. Clinicians recognized the need to deliver a more concentrated sodium solution and ordered that the IV fluid be changed to a 500 mL bag of 0.9% NaCl with heparin. However, due to a natural disaster affecting the supply chain for IV fluids, 0.9% NaCl 500 mL bags were in short supply, and the order was modified to use 100 mL 0.9% NaCl bags, which were available. Since the total volume was much smaller, a lower concentration formulation of heparin was required. However, the verifying pharmacist discovered that an 10-fold higher concentration had been used to compound the fluids, and further investigation revealed this same error had occurred on five other occasions.
Don C. Rockey, MD| August 21, 2014
Presenting with jaundice and epigastric pain, a woman with a history of multiple malignancies was admitted directly for an ultrasound-guided liver biopsy. After the procedure, the patient had low blood pressure and complained of new abdominal pain, which worsened over the next 2 hours. The bedside nurse soon found the patient unresponsive.
Michelle Feil, MSN, RN| June 1, 2014
Following removal of a central venous catheter placed during his admission for a prolonged course of intravenous antibiotics, a young man with a history of Behçet disease was discharged from the hospital. Shortly thereafter, he presented to the emergency department with acute onset shortness of breath and a "whistling sound" coming from his neck. Diagnosed with air embolism, he was admitted to the ICU.
Paul C. Walker, PharmD, and Jerod Nagel, PharmD| April 1, 2014
Following a hospitalization for Clostridium Difficile–associated diarrhea, a woman with HIV/AIDS and B-cell lymphoma was discharged with a prescription for a 14-day course of oral vancomycin solution. At her regular retail pharmacy, she was unable to obtain the medicine, and while awaiting coverage approval, she received no treatment. Her symptoms soon returned, prompting an emergency department visit where she was diagnosed with toxic megacolon.
Annie Yang, PharmD, BCPS| February 1, 2014
Despite multiple checks by physician, pharmacist, and nurse during the medication ordering, dispensing, and administration processes, a patient received a 10-fold overdose of an opioid medication and a code blue was called.
Karen Ousey, PhD, RGN| February 1, 2014
A patient admitted for acute liver failure, acute renal failure, respiratory failure, and hepatic encephalopathy had a rectal tube placed to manage diarrhea. Two weeks into his hospitalization, dark red liquid stool was noted in the rectal tube, and the patient was found to have a large ulcerated area in the rectum, likely caused by the tube.
Margaret C. Fang, MD, MPH| December 1, 2013
Two days after knee replacement surgery, a woman with a history of deep venous thrombosis receiving pain control via epidural catheter was restarted on her outpatient dose of rivaroxaban (a newer oral anticoagulant). Although the pain service fellow scanned the medication list for traditional anticoagulants, he did not notice the patient was taking rivaroxaban before removing the epidural catheter, placing the patient at very high risk for bleeding.
Joseph G. Ouslander, MD, and Alice Bonner, PhD, GNP| December 1, 2013
Following a lengthy hospitalization, an elderly woman was admitted to a skilled nursing facility for further care, where staff expressed concern about the complexity of the patient's illness. A few days later, the patient developed a fever and shortness of breath, prompting readmission to the acute hospital.
Laxmaiah Manchikanti, MD, and Joshua A. Hirsch, MD| September 1, 2013
Hospitalized for pneumonia and asthma, a man with chronic pain was found to be using pain medications not prescribed to him. During his hospitalization, the pain service was consulted and changed his medications to better control the pain. Five days after discharge, the patient died, presumably from an unintentional overdose of his old and new prescriptions.
Ashish C. Sinha, MD, PhD| August 21, 2013
Following general anesthesia for hip repair surgery, an elderly woman with a history of hypertension and obesity developed hypercarbic respiratory failure and was reintubated in the recovery unit. Providers felt the patient had undiagnosed obstructive sleep apnea and questioned whether obese patients undergoing anesthesia should receive formal preoperative screening for it.
Nicholas Symons, MBChB, MSc| August 21, 2013
An elderly woman with severe abdominal pain was admitted for an emergency laparotomy for presumed small bowel obstruction. Shortly after induction of anesthesia, her heart stopped. She was resuscitated and transferred to the intensive care unit, where she died the next morning. The review committee felt this case represented a diagnostic error, which led to unnecessary surgery and a preventable death.
Joseph I. Boullata, PharmD, RPh, BCNSP| April 1, 2013
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.
Admitted to the hospital with headache and word-finding difficulties, a man was given a preliminary diagnosis of vasculitis. Although serial imaging studies seemed to indicate progression of his brain lesions, these were not biopsied and discovered to be glioblastoma multiforme until 4 months later. The delay in diagnosis contributed to his rapid clinical decline.