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: February 1, 2023

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Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.

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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Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.

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

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Hospital-Acquired Diabetic Ketoacidosis.

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

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Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma.

Claire E. Graves, MD and Maggie A. Kuhn, MD, MAS | February 1, 2023

These cases describe the rare but dangerous complication of hematoma following neck surgery. The first case involves a patient with a history of spinal stenosis who was admitted for elective cervical discectomy and cervical disc arthroplasty who went... Read More

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Saved by ECMO

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.

Submit Your Case

All WebM&M: Case Studies (18)

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Displaying 1 - 18 of 18 WebM&M Case Studies

Delayed Diagnosis of Mesenteric Ischemia

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

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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 the patient was reassured that her symptoms should abate. The patient was seen by her PCP and visited the Emergency Department (ED) several times over the next six months. At each ED visit, the patient’s labs were normal and no imaging was performed. A second gastroenterologist suggested a diagnosis of intestinal ischemia to the patient, her primary gastroenterologist, her PCP, and endocrinologist but the other physicians did not follow up on the possibility of mesenteric ischemia. On another ED visit, the second gastroenterologist consulted a surgeon, and a mesenteric angiogram was performed, confirming a diagnosis of mesenteric ischemia with gangrenous intestines. The patient underwent near-total intestinal resection, developed post-operative infections requiring additional operations, experienced cachexia despite parenteral nutrition, and died of sepsis 3 months later. The commentary discusses the importance of early diagnosis of mesenteric ischemia and how to prevent diagnostic errors that can impede early identification and treatment.

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Getting the Diagnosis Both Right and Wrong

Andrew P. Olson, MD| September 25, 2019

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A woman with acute myeloid leukemia presented to the emergency department (ED) with shortness of breath after receiving chemotherapy. As laboratory test results showed acute kidney injury and suggested tumor lysis syndrome, the patient was started on emergent hemodialysis. She experienced worsening dyspnea and was emergently intubated and transferred to the intensive care unit. There, her blood pressure began to drop, and she died despite aggressive measures. During the code, the laboratory called with positive blood culture results; although blood cultures and broad-spectrum antibiotics had been ordered while the patient was in the ED, the antibiotics were not administered until several hours later. Due to the urgent focus on the patient's oncologic emergency, the diagnosis of sepsis was missed.

Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout

Allan S. Frankel, MD; Kathryn C. Adair, PhD; and J. Bryan Sexton, PhD| June 1, 2019

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A proceduralist went to perform ultrasound and thoracentesis on an elderly man admitted to the medicine service with bilateral pleural effusions. Unfortunately, he scanned the wrong patient (the patient had the same last name and was in the room next door). When the patient care assistant notified the physician of the error, he proceeded to scan the correct patient. He later nominated the assistant for a Stand Up for Safety Award.

Hip Fractures in Older Patients: the Case for Geriatrics Comanagement

Stephanie Rogers, MD, and Derek Ward, MD| April 1, 2019

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An elderly man with a complicated medical history slipped on a rug at home, fell, and injured his hip. Emergency department evaluation and imaging revealed no head injury and a left intertrochanteric hip fracture. Although he was admitted to the orthopedic surgery service, with surgery to fix the fracture initially scheduled for the next day, the operation was delayed by 3 days due to several emergent trauma cases and lack of surgeon availability. He ultimately underwent surgery and was discharged a few days later but was readmitted several weeks later with chest pain and shortness of breath. He was found to have a pulmonary embolism; anticoagulation was initiated. The patient's rehabilitation was delayed, his recovery was prolonged, and he never returned to his baseline functional status.

Cognitive Overload in the ICU

Vimla L. Patel, PhD, and Timothy G. Buchman, PhD, MD| August 21, 2016

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Admitted to the intensive care unit (ICU) with acute respiratory distress syndrome due to severe pancreatitis, an older woman had a central line placed. Despite maximal treatment, the patient experienced a cardiac arrest and was resuscitated. The intensivist was also actively managing numerous other ICU patients and lacked time to consider why the patient's condition had worsened.

Duty to Disclose Someone Else's Error?

Thomas H. Gallagher, MD| May 1, 2011

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Transferred to a tertiary hospital, a child with severe swelling of the brain is found to have venous sinus thromboses and little chance of survival. Further review revealed that the referring hospital had missed subtle signs of cerebral edema on the initial CT scan days earlier, raising the question of whether to disclose the errors of other facilities or caregivers.

Danger in Disruption

Dorrie K. Fontaine, RN, PhD| October 1, 2009

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A toddler admitted for severe dehydration requires a femoral IV. The anesthesiologist ignores a nurse's reminder that hospital policy requires monitoring if a child is to receive sedation in the unit. When the nurse attempts to stop the procedure, the anesthesiologist throws the needle to the floor.

Eptifibatide Epilogue

William W. Churchill, MS, RPh; Karen Fiumara, PharmD| April 1, 2009

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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.

Failure to Latch

Mitch Rodriguez, MD, MBA; Rebecca Mannel, BS, IBCLC; Donna Frye, RN, MN| September 1, 2008

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After several pediatric visits, parents of a newborn with low output and weight loss contact a lactation consultant, who discovered that ankyloglossia (tongue-tie) was preventing the infant from receiving adequate intake from breastfeeding.

The Inside of a Time Out

David L. Feldman, MD, MBA| May 1, 2008

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Prior to surgery, an anesthesiologist and surgical physician assistant noted a patient's allergy to IV contrast dye, but no order was written. During a time out before the procedure, an operative nurse raised concern about the allergy, but the attending anesthesiologist was not present and the resident did not speak up.

Do Not Disturb!

F. Daniel Duffy, MD; Christine K. Cassel, MD| October 1, 2007

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Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.

Medication Reconciliation: Whose Job Is It?

Eric G. Poon, MD, MPH| September 1, 2007

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Hospitalized for surgery, a woman with a history of seizures was given an overdose of the wrong medicine due to multiple errors, including an inaccurate preadmission medication list, failure to verify medication history, and uncoordinated information systems.

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.

Triple Handoff

Arpana R. Vidyarthi, MD| September 1, 2006

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An elderly man was admitted to the hospital for pacemaker placement. Although the postoperative chest film was normal, the patient later developed shortness of breath. Over the course of several nursing and physician shift changes and signouts, results of a follow-up stat x-ray are not properly obtained, delaying discovery of the patient's pneumothorax.

Right? Left? Neither!

Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD, MPP, MPH| May 1, 2006

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A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.

Is the "Surgical Personality" a Threat to Patient Safety?

Charles L. Bosk, PhD| April 1, 2006

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Because members of the OR team were reluctant to speak up to a senior surgeon with a reputation for yelling, a child undergoing surgery experiences a complication and has a delay in chemotherapy.

PCA Overdose

D. John Doyle, MD, PhD | August 21, 2005

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Following surgery, a woman receives morphine via a patient-controlled analgesia (PCA) pump. A few hours after arriving on the floor, she is found barely breathing.

On O.R. Off?

Michael Leonard, MD| March 1, 2005

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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.

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