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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: August 31, 2022
Commentary by Jennifer Rosenthal, MD, MAS and Michelle Hamline, MD, PhD, MAS | August 31, 2022

A 2-year-old girl presented to her pediatrician with a cough, runny nose, low grade fever and fatigue; a nasal swab for SARS-CoV-2 and influenza was negative and lung sounds were clear. The patient developed a fever and labored breathing and was... Read More

Spotlight Case
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Anamaria Robles, MD, and Garth Utter, MD, MSc | August 31, 2022

A 49-year-old woman was referred by per primary care physician (PCP) to a gastroenterologist for recurrent bouts of abdominal pain, occasional vomiting, and diarrhea. Colonoscopy, esophagogastroduodenoscopy, and x-rays were interpreted as normal, and... Read More

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Samantha Brown, MD, John S. Rose, MD, and David K. Barnes, MD | August 31, 2022

A 71-year-old man presented to a hospital-based orthopedic surgery clinic for a follow-up evaluation of his knee and complaints of pain and swelling in his right shoulder. His shoulder joint was found to be acutely inflamed and purulent fluid was... Read More

Samson Lee, PharmD, and Mithu Molla, MD, MBA | August 5, 2022

This WebM&M highlights two cases where home diabetes medications were not reviewed during medication reconciliation and the preventable harm that could have occurred. The commentary discusses the importance of medication reconciliation, how to... 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 (23)

1 - 20 of 23 WebM&M Case Studies
Candice Sauder, MD, MS, MEd, FACS and Kara T Kleber, MD, MA| January 7, 2022

A 52-year-old woman presented for a lumpectomy with lymphoscintigraphy and sentinel lymph node biopsy (SLNB) after being diagnosed with ductal carcinoma in situ (DICS). On the day of surgery, the patient was met in the pre-operative unit by several different providers (pre-operative nurse, resident physician, attending physician, and anethesiology team) to help prepare her for the procedure. In the OR, the surgical team performed two separate time-outs while the patient was being prepped, placed under general anesthesia, and draped. After the attending physician began operating, she realized that no radiotracer dye had been injected for the SNLB – a key process step that was supposed to have occurred prior to the surgery. The nuclear medicine team never saw the patient preoperatively, and none of the staff members or teams realized this until the patient was under general anesthesia with an open incision. The commentary discusses how pre-operative checklist protocols can help multidisciplinary teams avoid communication errors and reduce opportunities for adverse events.

Marissa G. Vadi, MD, MPH, and Mathew R. Malkin, MD | October 27, 2021

A 6-week-old infant underwent a craniotomy and excision of abnormal brain tissue for treatment of hemimegalencephaly and epilepsy. A right femoral central venous catheter and an arterial catheter were inserted, as well as 22-gauge intravenous catheter inserted into the external jugular vein, which was covered with surgical drapes.  During the surgical procedure, the neurosurgeon adjusted the patient’s head, displacing the external jugular intravenous catheter into the subcutaneous tissue.  The catheter’s dislodgment went unnoticed due to its position underneath the surgical drapes. The commentary discusses the importance intraoperative monitoring of intravenous catheters and the use of surgical safety checklists to improve communication and prevent surgical complications.

A seven-year-old girl with esophageal stenosis underwent upper endoscopy with esophageal dilation under general anesthesia. During the procedure, she was fully monitored with a continuous arterial oxygen saturation probe, heart rate monitors, two-lead electrocardiography, continuous capnography, and non-invasive arterial blood pressure measurements. The attending gastroenterologist and endoscopist were serially dilating the esophagus with larger and larger rigid dilators when the patient suddenly developed hypotension. She was immediately given a fluid bolus, phenylephrine, and 100% oxygen but still developed cardiac arrest. Cardiopulmonary resuscitation was initiated with cardiac massage, but she could not be resuscitated and died. This commentary highlights the role of communication between providers, necessary technical steps to mitigate the risks of upper endoscopy in children, and the importance of education and training for care team members.

A 61-year-old male was admitted for a right total knee replacement under regional anesthesia. The surgeon – unaware that the anesthesiologist had already performed a right femoral nerve block with 20 ml (100mg) of 0.5% racemic bupivacaine for postoperative analgesia – also infiltrated the arthroplasty wound with 200 mg of ropivacaine. The patient was sedated with an infusion of propofol throughout the procedure. At the end of the procedure, after stopping the propofol infusion, the patient remained unresponsive, and the anesthesiologist diagnosed the patient with Local Anesthetic Systemic Toxicity (LAST). The commentary addresses the symptoms of LAST, the importance of adhering to local anesthetic dosing guidelines, and the essential role of effective communication between operating room team members.

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.
Ken Catchpole, PhD| August 1, 2017
Because the plan to biopsy a large gastric mass concerning for malignancy was not conveyed to the hospitalist caring for the patient, she was not made NPO, nor was her anticoagulant medication stopped. The nurse anesthetist performing the preanesthesia checklist noted she received her anticoagulation that morning but did not notify the gastroenterologist. The patient had postprocedural bleeding.
Sonya P. Mehta, MD, MHS, and Karen B. Domino, MD, MPH| April 1, 2015
During laparoscopic subtotal colon resection for adenocarcinoma, a patient's bladder was accidentally lacerated and surgeons repaired it without difficulty. As nurses set up bladder irrigation equipment, no one noticed the bag of solution was dripping into the power supply of an anesthesiology monitor. Suddenly sparks and flames began shooting from the monitor, and the OR filled with black smoke. Fortunately, the fire was extinguished quickly and neither the patient nor any OR staff was injured.
Krishna Moorthy, MD, MS| January 1, 2015
Following outpatient laparoscopic surgery to repair an inguinal hernia, a man with no significant past medical history had high levels of pain at the surgical site and was admitted to the hospital. With sustained pain on postoperative day 3, the patient developed tachycardia with abdominal distension and a low-grade fever. A CT scan revealed a bowel perforation, which required surgery and a lengthy ICU stay due to septicemia.
John H. Eichhorn, MD| January 1, 2015
While undergoing an elective coronary artery bypass graft (CABG) and ablation, an elderly man had a pulmonary artery catheter (PAC) placed to monitor his hemodynamic status. During the operation, the team was informed that another patient needed an emergency CABG. In the rush to attend to the second patient, the PAC in the first was left inflated for a prolonged period, which could have led to a catastrophic complication.
Edward A. Bittner, MD, PhD| February 1, 2011
Following elective anterior cervical discectomy, a patient developed tightness and swelling in his neck. Later, the patient stood up, turned blue, and fell to the floor unconscious. An obvious neck hematoma was compromising his airway, and the patient required an emergency tracheostomy and CPR.
Christopher R. Lee, MD| October 1, 2009
Following surgery for peripheral vascular disease, a patient otherwise ready for discharge complains of liquid shooting from his nose. The surgeons make the patient NPO and order a consultation from an otolaryngologist, who discovers the nasopharyngeal airway still lodged in the patient's nasal cavity.
Tracy Minichiello, MD| March 1, 2005
Despite a box on the admission form warning against using blood thinners and epidural anesthesia together, a patient admitted for elective surgery receives both, and becomes permanently paralyzed.
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.
Kay Ball, RN, MSA | October 1, 2004
While repositioning the trocar, a surgeon places the laparoscope on a tray sitting on the patient. When she picks it back up, she notices that the drape has melted and the patient has a second-degree burn.
Stephen G. Pauker, MD; Susan P. Pauker, MD| May 1, 2004
Owing to privacy concerns, a nurse draws the drapes on a 3-year-old child in recovery following surgery, and unfortunately does not realize the child is in distress until loud inspiratory stridor is heard.
Haya R. Rubin, MD, PhD; Vera T. Fajtova, MD| May 1, 2004
To achieve tight glucose control, a hospitalized diabetes patient is placed on an insulin drip. Prior to minor surgery, he is made NPO and becomes severely hypoglycemic.
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.