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: November 30, 2023

New

When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!

Berit Bagley, RN, MSN, CDCES, BC-ADM, Charity L. Tan, MSN, ACNP-BC, CDCES, BC-ADM, Deborah Plante, MD | November 30, 2023

A 67-year-old man with well-controlled type 2 diabetes mellitus underwent elective cardiac... Read More

New

Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon

Christian Bohringer, MBBS, and Sharon Ashley, MD | November 30, 2023

A 38-year-old woman with class 3 obesity required removed of a gastric balloon under general anesthesia.... Read More

New

Medication Mix-Up Leads to Patient Death

Luciano Sanchez, PharmD and Patrick Romano, MD, MPH | November 30, 2023

An 81-year-old man was admitted to the intensive care unit (ICU) with a gastrointestinal bleed and referred for a diagnostic colonoscopy. The nurse preparing... Read More

Spotlight Case

CE/MOC

New

The Risks of a Malpositioned Gastrostomy Tube and Poor Communication

Rachel Ann Hight, MD, FACS | November 29, 2023

This case describes a 55-year-old woman who sustained critical injuries after a motor vehicle crash and had a lengthy... Read More

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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 (19)

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Displaying 1 - 19 of 19 Results

Premature Closure: Was It Just Syncope?

David Maurier, MD and David K. Barnes, MD | November 25, 2020

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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.

The Forgotten Radiographic Read

Clinton J. Coil, MD, MPH, and Mallory D. Witt, MD| September 1, 2017

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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.

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.

Abdominal Pain in Early Pregnancy

Charlie C. Kilpatrick, MD| September 1, 2015

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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.

Misleading Complaint

Krishan Soni, MD, MBA, and Gurpreet Dhaliwal, MD| July 1, 2012

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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.

The Dropped "No"

Annette J. Johnson, MD, MS| October 1, 2011

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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.

"Superficial" Report Leads to "Deep" Problem

Gurpreet Dhaliwal, MD| December 1, 2009

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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.

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.

Where's the Feeding Tube?

Norma A. Metheny, RN, PhD; Kathleen L. Meert, MD| September 1, 2008

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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.

On the Other Hand

Elizabeth A. Henneman, RN, PhD| May 1, 2007

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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.

Hidden Mystery

Douglas D. Brunette, MD| March 1, 2005

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The challenges of examining and imaging a hospitalized morbidly obese patient delay diagnosis, threatening the patient's life.

Glucose Roller Coaster

Bradley A. Sharpe, MD| July 1, 2004

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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.

Fumbled Handoff

Arpana Vidyarthi, MD| March 1, 2004

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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.

X-ray Flip

Marc J. Shapiro, MD| February 1, 2004

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Trusting an incorrectly labeled chest x-ray over physical exam findings, a resident places a chest tube for pneumothorax in the wrong side.

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 testiclewithout realizing that his right testicle had been removed previously.

Did We Forget Something?

Verna C. Gibbs, MD| September 1, 2003

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A patient dies from infection and complications months after surgery; a retained sponge is found at autopsy.

Inappropriate Antibiotic Use

Hilary M. Babcock, MD; Victoria J. Fraser, MD| June 1, 2003

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Antibiotics continued in a patient with no clear source of infection for 3 weeks results in hospital-acquired superinfections.

Not a Miscarriage

Lee A. Learman, MD, PhD| June 1, 2003

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A woman was told she miscarried, even though she was still pregnant.

Ectopic or Not?

Vanessa M. Givens, MD; Gary H. Lipscomb, MD| May 1, 2003

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A woman is given methotrexate prematurely for suspected ectopic pregnancy and ultimately has salpingectomy.

WebM&M: Case Studies

This Month's WebM&Ms

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