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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 (10)

Displaying 1 - 10 of 10 WebM&M Case Studies
Alexandria DePew, MSN, RN, James Rice, & Julie Chou, BSN | May 16, 2022

This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.

Michael J. Barrington, MBBS, PhD, and Yoshiaki Uda, MBBS| April 1, 2017
An older woman admitted to the medical-surgical ward with multiple right-sided rib fractures received a paravertebral block to control the pain. After the procedure, the anesthesiologist realized that the block had been placed on the wrong side. The patient required an additional paravertebral block on the correct side, which increased her risk of complications and exposed her to additional medication.
Kerm Henriksen, PhD; Kendall K. Hall, MD, MS| June 1, 2011
Admitted to the hospital with community-acquired pneumonia, an elderly man nearly receives dangerous potassium supplementation due to a “critical panic value” call for a low potassium in another patient.
Dorothy Dougherty, RN| November 1, 2010
A hospitalized 2-month-old infant is fed breast milk from another infant's mother after the wrong bottle is pulled from the ward's refrigerator.
Michael Astion, MD, PhD | December 1, 2006
A man admitted to the hospital for elective surgery has blood drawn. Despite a policy for proper identification, the blood samples were all mislabeled with another patient's name. The error was discovered at the lab, and there was no harm to the patient.
Dennis S. O'Leary, MD; William E. Jacott, MD| December 1, 2004
Despite a "time out" and having his leg marked by the surgeon, a patient comes perilously close to having surgery on the wrong leg.
Peter Lindenauer, MD, MSc| October 1, 2004
A surgical patient and a neurosurgical patient are scheduled to be moved to different beds, the second taking the first's spot. However, the move is documented electronically before it occurs physically, and a medication error nearly ensues.
Harold S. Kaplan, MD| February 1, 2004
Blood typing tubes for a married couple brought to an ED after a trauma are labeled with the opposite stickers. By coincidence, the wife's blood type was already on file. An alert blood-bank technologist catches the mistake.
Albert W. Wu, MD, MPH; Peter J. Pronovost, MD, PhD| January 1, 2004
A patient receiving end-of-life care, whose code status was DNR, encounters a potentially life-threatening medication error.
Marilynn M. Rosenthal, PhD| July 1, 2003
An anxious patient awaiting ambulatory surgery is mistakenly put on the wrong operating table.