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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 (19)

Displaying 1 - 19 of 19 WebM&M Case Studies
David Maurier, MD and David K. Barnes, MD | November 25, 2020

A 60-year-old male presented to the emergency department (ED) with his partner after an episode of dizziness and syncope when exercising. An electrocardiogram demonstrated non-ST-elevation myocardial infarction abnormalities. A brain CT scan was ordered but the images were not assessed prior to initiation of anticoagulation treatment. While awaiting further testing, the patient’s heart rate slowed and a full-body CT scan demonstrated an intracranial hemorrhage. An emergent craniotomy was performed and the patient later died. The commentary discusses the influence of cognitive errors and the high-risk nature of anticoagulation contributing to this medical error, and the use of systematic interventions such as checklists and forcing functions to mitigate cognitive biases and prevent adverse outcomes.

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Clinton J. Coil, MD, MPH, and Mallory D. Witt, MD| September 1, 2017
A woman developed sudden nausea and abdominal distension after undergoing inferior mesenteric artery stenting. The overnight intern forgot to follow up on her abdominal radiograph, which resulted in a critical delay in diagnosing acute mesenteric artery dissection and bowel infarction.
James B. Reilly, MD, MS, and Christopher Webster, DO| March 1, 2017
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.
Charlie C. Kilpatrick, MD| September 1, 2015
After several days of abdominal pain, nausea, and vomiting, a pregnant woman visited the emergency department and was swiftly discharged with antibiotics for a UTI. However, she returned the next day with unchanged abdominal pain and more nausea and vomiting. Apart from a focused ultrasound to document her pregnancy, no further testing was done. The patient again returned the following day with increased pain and now appeared more ill. An MRI revealed a ruptured appendix.
Krishan Soni, MD, MBA, and Gurpreet Dhaliwal, MD| July 1, 2012
A man presented to the emergency department (ED) complaining of knee problems, and the triage nurse wrote down the chief complaint as "bilateral knee pain." The ED physician diagnosed a musculoskeletal injury and prepared to discharge him, but the patient was noticeably unsteady. Further examination and imaging revealed a subdural hematoma requiring urgent neurosurgical intervention.
Annette J. Johnson, MD, MS| October 1, 2011
When a hospitalized man developed an arrhythmia, the night float resident checked a radiology report that stated the patient had a DVT. Intervention was started based on that assumption. However, the radiology report had been transcribed incorrectly.
Gurpreet Dhaliwal, MD| December 1, 2009
Physicians confuse the terminology on a preliminary radiology report and diagnose a woman with foot and ankle pain as having a low-risk case of superficial vein thrombosis, rather than the more dangerous deep vein thrombosis she actually had.
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.
Norma A. Metheny, RN, PhD; Kathleen L. Meert, MD| September 1, 2008
A boy was receiving enteral feedings while recovering from a traumatic brain injury. The nasojejunal tube migrated to the gastric area, and the patient developed pneumonia, likely due to aspiration.
Elizabeth A. Henneman, RN, PhD| May 1, 2007
A young woman with Takayasu's arteritis, a vascular condition that can cause BP differences in each arm, was mistakenly placed on a powerful intravenous vasopressor because of a spurious low BP reading. The medication could have led to serious complications.
Douglas D. Brunette, MD| March 1, 2005
The challenges of examining and imaging a hospitalized morbidly obese patient delay diagnosis, threatening the patient's life.
Bradley A. Sharpe, MD| July 1, 2004
A woman hospitalized for CHF (with no history of diabetes) is given several rounds of insulin and D50, after repeated blood tests show her glucose to be dangerously high, then dangerously low. Turns out, the blood samples were drawn incorrectly and the signouts were incomplete.
Arpana Vidyarthi, MD| March 1, 2004
Due to a series of incomplete signouts, information about a patient's post-operative leg pain and chest discomfort is not conveyed to the primary team. A PE is discovered post-mortem.
Marc J. Shapiro, MD| February 1, 2004
Trusting an incorrectly labeled chest x-ray over physical exam findings, a resident places a chest tube for pneumothorax in the wrong side.
J. Forrest Calland, MD| January 1, 2004
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.
Hilary M. Babcock, MD; Victoria J. Fraser, MD| June 1, 2003
Antibiotics continued in a patient with no clear source of infection for 3 weeks results in hospital-acquired superinfections.
Vanessa M. Givens, MD; Gary H. Lipscomb, MD| May 1, 2003
A woman is given methotrexate prematurely for suspected ectopic pregnancy and ultimately has salpingectomy.