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.

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This Month's WebM&Ms

Update Date: March 15, 2023

Spotlight Case

CE/MOC

New

Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation

Jonathan Trask, RN, Kathleen M. Carlsen, PA, Brooks T. Kuhn, MD | March 15, 2023

A 72-year-old man was diagnosed with COVID-19 pneumonia and ileus, and admitted to a specialized COVID care unit. A nasogastric tube (NGT) was placed, supplemental oxygen was provided, and oral feedings were... Read More

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New

Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists

Lucy Shi, MD and Erik Noren MD, MS | March 15, 2023

A 71-year-old man presented to his physician with rectal bleeding and pain, which was attributed to radiation proctitis following therapy for adenocarcinoma of the prostate. He subsequently developed a potentially life... Read More

New

Medication Handling and Compounding Errors in the Operating Room.

Joy Chaudhry, PharmD, BCPS, BCCCP, Julie Chou BSN, RN, CNOR, Courtney Manning, PharmD, MBA, Minji Kim, RN, BSN, CNOR, and David Dakwa, PharmD, MBA, BCPS, BCSCP | March 15, 2023

This case focuses on immediate-use medication compounding in the operating room and how the process creates situations in which medication errors can occur. The commentary discusses strategies for safe perioperative compounding and the... Read More

New

Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm.

Christian Bohringer, MD | March 15, 2023

A 48-year-old woman was placed under general anesthesia with a laryngeal mask. The anesthesiologist was distracted briefly to sign for opioid drugs in a register, and during this time,... Read More

New

Duplicate Therapies in Retail Pharmacy

Nisha Punatar, MD, Samson Lee, PharmD, BCACP, and Mithu Molla, MD, MBA | March 15, 2023

The cases described in this WebM&M reflect fragmented care with lapses in coordination and communication as well as failure to appropriately address medication discrepancies. These two cases involve duplicate therapy errors, which have the potential to cause... 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.

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All WebM&M: Case Studies (24)

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Displaying 1 - 20 of 24 WebM&M Case Studies

Complaints as Safety Surveillance

Jennifer Morris and Marie Bismark, MD| September 1, 2016

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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.

More Treatment—Better Care?

Rita Redberg, MD, MSc| December 1, 2011

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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.

Duty to Disclose Someone Else's Error?

Thomas H. Gallagher, MD| May 1, 2011

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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.

Outbreak

Richard Rothman, MD, PhD; Sahael Stapleton, MD| May 1, 2011

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An emergency department worker develops chicken pox following an exposure during one of his shifts.

Are We Pushing Graduate Nurses Too Fast?

Nancy Spector, PhD, RN | March 1, 2011

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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.

One Toxic Drug Is Not Like Another

Eric S. Holmboe, MD| February 1, 2011

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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.

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" Appendicitis

Caprice C. Greenberg, MD, MPH| October 1, 2010

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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.

Defensive Medicine: "Glowing" with Pain

Manish K. Sethi, MD| February 1, 2010

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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.

Round-Trip Service

Mary H. McGrath, MD, MPH| December 1, 2009

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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.

Difficult Encounters: A CMO and CNO Respond

Ernest J. Ring, MD; Jane E. Hirsch, RN, MS| October 1, 2009

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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.

All in the History

Christopher Fee, MD| March 21, 2009

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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.

To Transfer or Not to Transfer

Jesse M. Pines, MD, MBA, MSCE| January 1, 2009

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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.

Code Blue—Where To?

Bruce D. Adams, MD| October 1, 2007

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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.

Abnormal Volunteer Results

Conrad V. Fernandez, MD| June 1, 2007

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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.

Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality

Peter Lindenauer, MD, MSc| November 1, 2006

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A woman with end stage renal disease and heart disease on anticoagulation receives a pneumonia vaccination that causes a large hematoma.

Liposuction Gone Awry

James A. Yates, MD| March 1, 2006

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A man undergoes plastic surgery at an outpatient center and winds up with a complication requiring prolonged stay in the ICU.

Collegiality vs. Competence

Todd Sagin, MD, JD| March 1, 2006

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Despite formal investigation of complications in past cases, a senior surgeon is still allowed to operate on a patient, with disastrous results.

PCA Overdose

D. John Doyle, MD, PhD | August 21, 2005

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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.

Security Lapse

Daniel Mason, MD| September 1, 2004

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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.

WebM&M: Case Studies

This Month's WebM&Ms

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