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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: March 15, 2023
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
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.

All WebM&M: Case Studies (19)
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Displaying 1 - 19 of 19 WebM&M Case Studies
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    • Getting the Diagnosis Both Right and Wrong
    Andrew P. Olson, MD| September 25, 2019
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    • A woman with acute myeloid leukemia presented to the emergency department (ED) with shortness of breath after receiving chemotherapy. As laboratory test results showed acute kidney injury and suggested tumor lysis syndrome, the patient was started on emergent hemodialysis. She experienced worsening dyspnea and was emergently intubated and transferred to the intensive care unit. There, her blood pressure began to drop, and she died despite aggressive measures. During the code, the laboratory called with positive blood culture results; although blood cultures and broad-spectrum antibiotics had been ordered while the patient was in the ED, the antibiotics were not administered until several hours later. Due to the urgent focus on the patient's oncologic emergency, the diagnosis of sepsis was missed.
    Spinal Epidural Abscess
    Yi Lu, MD, PhD, and Douglas Salvador, MD, MPH| August 8, 2019
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    • A woman with a history of prior spine surgery presented to the emergency department with progressive low back pain. An MRI scan of T11–S1 showed lumbar degenerative joint disease and a small L5–S1 disc herniation. She was referred for physical therapy and prescribed muscle relaxant, non-steroidal anti-inflammatories, and pain relievers. Ten days later, she presented to a community hospital with fever, inability to walk, and numbness from the waist down. Her white blood cell count was greater than 30,000 and she was found to be in acute renal and liver failure. She was transferred to a neurosurgery service at an academic hospital when an MRI revealed a T6–T10 thoracic epidural abscess.
    Shortcuts to Acetaminophen-induced Liver Failure
    Stephen Bacak, DO, MPH, and Loralei Thornburg, MD| March 1, 2018
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    • A pregnant woman presented to the emergency department 3 times in 4 days, first with symptoms of upper respiratory infection, nausea, and fever; then abdominal cramps; then shortness of breath and abdominal pain. On the third visit, she was diagnosed with influenza and possible sepsis. In between visits, the patient had been taking acetaminophen (1g every 4 hours) to control her fever. Although she had signs of acute fulminant hepatitis due to acetaminophen overdose, administration of the antidote, N-acetylcysteine, was delayed for 10 hours.
    The Perils of Contrast Media
    Umar Sadat, MD, PhD, and Richard Solomon, MD| June 1, 2017
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    • To avoid worsening acute kidney injury in an older man with possible mesenteric ischemia, the provider ordered an abdominal CT without contrast, but the results were not diagnostic. Shortly later, the patient developed acute paralysis, and an urgent CT with contrast revealed blockage and a blood clot.
    Diagnostic Overshadowing Dangers
    Maria C. Raven, MD, MPH, MSc| June 1, 2017
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    • Presenting with pain in her epigastric region and back, an older woman with a history of opioid abuse had abnormal vital signs and an elevated troponin level. Imaging revealed multiple spinal fractures and cord compression. Neurosurgery recommended conservative management overnight. However, her troponin levels spiked, and an ECG revealed myocardial infarction.
    Diagnostic Delay in the Emergency Department
    Kyle Marshall, MD, and Hardeep Singh, MD, MPH| May 1, 2017
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    • Emergency department evaluation of a man with morbid obesity presenting with abdominal pain revealed tachycardia, hypertension, elevated creatinine, and no evidence of cholecystitis. Several hours later, the patient underwent CT scan; the physicians withheld contrast out of concern for his acute kidney injury. The initial scan provided no definitive answer. Ultimately, physicians ordered additional CT scans with contrast and diagnosed an acute aortic dissection.
    Hemolysis Holdup
    Christopher M. Lehman, MD| May 1, 2017
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    • In the emergency department, an older man with multiple medical conditions was found to have evidence of acute kidney injury and an elevated serum potassium level. However, the blood sample was hemolyzed, which can alter the reading. Although the patient was admitted and a repeat potassium level was ordered, the physician did not institute treatment for hyperkalemia. Almost immediately after the laboratory called with a panic result indicating a dangerously high potassium level, the patient went into cardiac arrest.
    Consequences of Medical Overuse
    Daniel J. Morgan, MD, MS, and Andrew Foy, MD| March 1, 2017
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    • Brought to the emergency department from a nursing facility with confusion and generalized weakness, an older woman was found to have an elevated troponin level but no evidence of ischemia on her ECG. A consulting cardiologist recommended treating the patient with three anticoagulants. The next evening, she became acutely confused and a CT scan revealed a large intraparenchymal hemorrhage with a midline shift.
    Diagnosing a Missed Diagnosis
    James B. Reilly, MD, MS, and Christopher Webster, DO| March 1, 2017
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    • A woman taking modified-release lithium for bipolar disorder was admitted with cough, slurred speech, confusion, and disorientation. Diagnosed with delirium attributed to hypercalcemia, she was treated with aggressive hydration. She remained disoriented and eventually became comatose. After transfer to the ICU, she was diagnosed with nephrogenic diabetes insipidus due to lithium toxicity.
    An Obstructed View
    Jonathan Carter, MD| October 1, 2015
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    • A patient with severe abdominal pain was admitted to the medicine service for observation, pain control, and serial abdominal examinations. Surgical consultation was not requested at admission. Two days later, the patient's abdomen worsened. Consultation led to urgent surgery, which revealed a strangulating bowel obstruction and associated perforation.
    Tough Call: Addressing Errors From Previous Providers
    William Martinez, MD, MS, and Gerald B. Hickson, MD| March 1, 2014
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    • Hospitalized 3 times within 2 months presumably for sepsis, a woman with diabetes on metformin presented to the emergency department with the same set of symptoms as her previous admissions. After reviewing her records, the admitting team determined that the patient's presentation for this and earlier admissions was more consistent with acute lactic acidosis secondary to metformin than sepsis.
    Pathologic Mistake
    Reza Alaghehbandan, MD, MSc, and Stephen S. Raab, MD| March 1, 2013
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    • A woman with abdominal pain, bloating, and weight loss went to her primary physician, who ordered imaging and a biopsy. Lymph node pathology was reported as Castleman disease. A specialist felt the presentation and test results were atypical for this diagnosis. Further testing revealed adult-onset celiac disease.
    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.
    Diagnosing HIV-It Doesn't Take a Brain Surgeon
    Roger Chou, MD| May 1, 2008
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    • Head imaging findings for a man admitted following new-onset headaches and a seizure revealed a brain mass. The patient was sent for craniotomy and brain biopsy, which revealed toxoplasmosis, prompting an HIV test that returned positive.
    Do Not Disturb!
    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.
    Diagnosing Diagnostic Mistakes
    Robert McNutt, MD; Richard Abrams, MD; Scott Hasler, MD| May 1, 2005
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    • Using past WebM&M cases, the authors discuss the challenges inherent in classifying diagnostic mistakes as medical errors.
    Inadvertent Castration
    J. Forrest Calland, MD| January 1, 2004
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    • During a hernia repair, surgeons decide to remove a patient's hydrocele, spermatic cord, and left testicle—without realizing that his right testicle had been removed previously.
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