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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: December 14, 2022
Narath Carlile, MD, MPH, Clyde Lanford Smith, MD, MPH, DTM&H, James H. Maguire, MD, and Gordon D. Schiff, MD | December 14, 2022

This case describes a man in his 70s with a history of multiple myeloma and multiple healthcare encounters for diarrhea in the previous five years, which had always been attributed to viral or unknown causes, without any microbiologic or serologic... Read More

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Naileshni S. Singh, MD | December 14, 2022

A 63-year-old woman was admitted to a hospital for anterior cervical discectomy (levels C4-C7) and plating for cervical spinal stenosis under general anesthesia. The operation was uneventful and intraoperative neuromonitoring was used to help prevent... Read More

Mark Fedyk, PhD, Nathan Fairman, MD, MPH, Patrick S. Romano, MD, MPH, John MacMillan, MD, and Monica Miller, RN, MS, CCRN | December 14, 2022

A 65-year-old man with metastatic liver disease presented to the hospital with worsening abdominal pain after a partial hepatectomy and development of a large ventral hernia. Imaging studies revealed perforated diverticulitis. A goals-of-care... 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 (22)

Displaying 1 - 20 of 22 WebM&M Case Studies
Jennifer Morris and Marie Bismark, MD| September 1, 2016
Assuming its dosing was similar to morphine, a physician ordered 4 mg of IV hydromorphone for a hospitalized woman with pain from acute pancreatitis. As 1 mg of IV hydromorphone is equivalent to 4 mg of morphine, this represented a large overdose. The patient was soon found unresponsive and apneic—requiring ICU admission, a naloxone infusion overnight, and intubation. While investigating the error, the hospital found other complaints against that particular physician.
Rita Redberg, MD, MSc| December 1, 2011
A patient with Guillain-Barré syndrome received more than the recommended number of plasmapheresis treatments. When the ordering physicians were asked why so many treatments were given, they both responded that the patient was improving so they felt that more treatments would help him recover even more.
Thomas H. Gallagher, MD| May 1, 2011
Transferred to a tertiary hospital, a child with severe swelling of the brain is found to have venous sinus thromboses and little chance of survival. Further review revealed that the referring hospital had missed subtle signs of cerebral edema on the initial CT scan days earlier, raising the question of whether to disclose the errors of other facilities or caregivers.
Richard Rothman, MD, PhD; Sahael Stapleton, MD| May 1, 2011
An emergency department worker develops chicken pox following an exposure during one of his shifts.
Nancy Spector, PhD, RN | March 1, 2011
While caring for a complex patient in the surgical intensive care unit, a nurse incorrectly set up the continuous renal replacement therapy (CRRT) machine, raising questions about how new nurses should be trained in high-risk procedures.
Eric S. Holmboe, MD| February 1, 2011
A man diagnosed with chronic hepatitis C was treated with interferon and ribavirin by his internist without referral for a liver biopsy or the appropriate blood tests. Treatment was continued for months despite the patient developing pancytopenia and continuing to have a high viral load, raising questions about physicians practicing outside their areas of competency.
Susan Barbour, RN, MS, FNP| December 1, 2010
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.
Caprice C. Greenberg, MD, MPH| October 1, 2010
Following an appendectomy, an elderly man continued to have right lower quadrant pain. Reviewing the specimen removed during the surgery, the pathologist found no appendiceal tissue. The patient was emergently taken back to the OR, and the appendix was located and removed.
Manish K. Sethi, MD| February 1, 2010
Over the course of 2 years, a patient who frequently came to the emergency department complaining of abdominal pain underwent 12 CT scans of the abdomen and pelvis. All of them were completely normal.
Mary H. McGrath, MD, MPH| December 1, 2009
Eager to have his knee replaced, an active older patient travels overseas for the surgery. At home 2 weeks later, he develops acute pain and swelling in his knee. A local orthopedic surgeon's office tells him to contact his operating physician, nearly 5000 miles away.
Ernest J. Ring, MD; Jane E. Hirsch, RN, MS| October 1, 2009
Cardiology consultation on an elderly man admitted to the orthopedic service following a hip fracture reveals aortic stenosis. The cardiologist recommends against surgery, due to the risk of anesthesia. When the nurse reads these recommendations to the orthopedic resident, he calls her "stupid" and contacts the OR to schedule the surgery anyway. The Chief Medical Officer is called to intervene.
Christopher Fee, MD| March 21, 2009
Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.
Jesse M. Pines, MD, MBA, MSCE| January 1, 2009
An elderly man, recently discharged from one hospital after having his automated internal cardioverter-defibrillator (AICD) replaced, is taken to another hospital when his AICD misfires multiple times.
Bruce D. Adams, MD| October 1, 2007
A code blue is called on an elderly man with a history of coronary artery disease, hypertension, and schizophrenia hospitalized on the inpatient psychiatry service. Housestaff covering the code team did not know where the service was located, and when the team arrived, they found their equipment to be incompatible with the leads on the patient.
Conrad V. Fernandez, MD| June 1, 2007
A healthy woman who volunteered to participate in a radiology study was notified several weeks later of a "major abnormality" discovered on her MRI. She sought further evaluation and was diagnosed with uterine cancer.
James A. Yates, MD| March 1, 2006
A man undergoes plastic surgery at an outpatient center and winds up with a complication requiring prolonged stay in the ICU.
D. John Doyle, MD, PhD | August 21, 2005
Following surgery, a woman receives morphine via a patient-controlled analgesia (PCA) pump. A few hours after arriving on the floor, she is found barely breathing.
Daniel Mason, MD| September 1, 2004
A medical student discovers that a hospital's radiology records are accessible via Internet, without any security, and struggles with whether and to whom to report the obvious HIPAA violation.
Bryan A. Liang, MD, PhD, JD| May 1, 2004
Understanding that she may lose her life without it, a woman severely injured in a collision rejects a blood transfusion for religious reasons. However, her parents persuade the physicians otherwise, and the woman lives.
Colin F. Mackenzie, MD| March 1, 2004
Video monitors near the operating room reveal a patient's identity, and gossip spreads about a very private issue.