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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: May 16, 2022
Garima Agrawal, MD, MPH, and Mithu Molla, MD, MBA | May 16, 2022

This WebM&M describes two cases involving patients who became unresponsive in unconventional locations – inside of a computed tomography (CT) scanner and at an outpatient transplant clinic – and strategies to ensure that all healthcare teams are... Read More

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... 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 (26)

1 - 20 of 26 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.

Lina Bergman, RN, MSc, and Wendy Chaboyer, RN, PhD| February 1, 2019
Following surgery under general anesthesia, a boy was extubated and brought to postanesthesia care unit (PACU). Due to the patient's age and length of the surgery, the PACU anesthesiologist ordered continuous pulse-oximetry monitoring for 24 hours. Deemed stable to leave the PACU, the boy was transported to the regular floor. When the nurse went to place the patient on pulse oximetry, she realized he was markedly hypoxic. She administered oxygen by face mask, but he became bradycardic and hypotensive and a code blue was called.
Jennifer Malana, MSN, RN, and Audrey Lyndon, PhD, RN| October 1, 2016
A pregnant woman was admitted for induction of labor for postterm dates. Prior to artificial rupture of membranes (AROM), the intern found a negative culture for group B strep in the hospital record but failed to note a positive culture in faxed records from an outside clinic. Another physician caught the error, ordered antibiotics, and delayed AROM to allow time for the medication to infuse.
Michael E. Detsky, MD, MSc| April 1, 2016
During a hospitalization after a cardiac arrest, an older man underwent placement of a PEG tube for nutrition, and an abdominal radiograph the next day showed "free air under the diaphragm." Although the resident got a "curbside consult" from surgery saying this finding should be monitored, the consult was not documented in the chart. Two days later, the patient was urgently taken to surgery to repair a large gastric perforation and spillage of tube feeds into the peritoneum and then transferred to the ICU in septic shock.
Marta L. Render, MD| May 1, 2012
After placing a central line in an elderly patient following a heart attack, a community hospital transferred him to a referral hospital for stenting of his coronary arteries. He was discharged to an assisted living facility 2 days later, with the central line still in place.
Albert Wu, MD, MPH| November 1, 2011
An elderly man discharged from the emergency department with syringes of anticoagulant for home use mistakenly picked up a syringe of atropine left by his bedside. At home the next day, he attempted to inject the atropine, but luckily was not harmed.
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.
Margaret Fang, MD, MPH; Raman Khanna, MD, MAS| July 1, 2011
Following hospitalization for community-acquired pneumonia, an elderly man with a history of dementia, falls, and atrial fibrillation is discharged on antibiotics but no changes to his anticoagulation medication. One week later, the patient’s INR was dangerously high.
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.
Ben-Tzion Karsh, PhD| March 1, 2011
A patient requiring orthopedic follow-up after an emergency department visit missed his appointment, and a secretary canceled the referral in the electronic medical record to minimize black marks on the hospital’s 30-day referral quality scorecard. Because the primary physician did not receive notice of the cancellation, follow-up was delayed.
William W. Churchill, MS, RPh; Karen Fiumara, PharmD| April 1, 2009
A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
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.
Emily S. Patterson, PhD| November 1, 2008
Due to lack of communication during shift change, an infant's transfer to a higher level of care is delayed. The infant develops respiratory distress, prompting a call to the rapid response team and transfer to the ICU.
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.
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.
Bernard Lo, MD| September 1, 2006
An elderly woman who had a DNR in place took a fall that required her to have surgery. Discussion with the patient's health care proxy led to the DNR order being suspended during surgery, with the understanding that it would be reinstated postoperatively. Several days later, a nurse noticed that patient remained 'full code' because the DNR had not been restored.
Hildy Schell, RN, MS, CCNS; Robert M. Wachter, MD| July 1, 2006
An elderly woman was transported to CT with no medical escort and an inadequate oxygen supply. She died later that day.
Tess Pape, PhD, RN, CNOR| February 1, 2006
Bypassing the safeguards of an automated dispensing machine in a skilled nursing facility, a nurse administers medications from a portable medication cart. A non-diabetic patient receives insulin by mistake, which requires his admission to intensive care and delays his chemotherapy for cancer.
Michael Leonard, MD| March 1, 2005
Surgeons cancel revascularization surgery on an elderly man so that he can first undergo cardiac catheterization. The next morning, the patient is taken to the OR anyway and given general anesthesia.
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.