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.

Submit Your Case

This Month's WebM&Ms

Update Date: February 1, 2023

Spotlight Case

CE/MOC

New

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

Take the Quiz

New

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

New

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

Spotlight Case

CE/MOC

New

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

Take the Quiz

New

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 (17)

Continue Education

Additional Filters

Approach to Improving Safety

Safety Target

Setting of Care

Clinical Area

Target Audience

Error Types

Clear all

Displaying 1 - 17 of 17 WebM&M Case Studies

When the Lytes Go Out: A Case of Inpatient Cardiac Arrest

Benjamin Stripe, MD, FACC, FSCAI and Dahlia Zuidema, Pharm.D, BC-ADM, CDCES | September 30, 2020

Save to Library

A 44-year old man with hypertension and diabetes was admitted with an open wound on the ball of his right foot that could be probed to the bone and evidence of diabetic ketoacidosis. Over the course of the hospitalization, he had ongoing hypokalemia, low magnesium levels, an electrocardiogram showing a prolonged QT interval, ultimately leading to cardiac arrest due to torsades de pointes (an unusual form of ventricular tachycardia that can be fatal if left untreated). The commentary discusses the use of protocol-based management of chronic medical conditions, the inclusion of interprofessional care teams to coordinate management, and the importance of inter-team communication to identify issues and prevent poor outcomes.

Take the Quiz

When the Indications for Drug Administration Blur

Julia Munsch, PharmD and Amy Doroy, PhD, RN | June 24, 2020

Save to Library

A 55-year old woman became unarousable with low oxygen saturation as a result of multiple intravenous benzodiazepine doses given overnight. The benzodiazepine was ordered following a seizure in the intensive care unit (ICU) and was not revised or discontinued upon transfer to the floor; several doses were given for different indications - anxiety and insomnia. This case illustrates the importance of medication reconciliation upon transition of care, careful implementation of medication orders in their entirety, assessment of patient response and consideration of whether an administered medication is working effectively, accurate and complete documentation and communication, and the impact of limited resources during night shift.

Take the Quiz

Life-Threatening Infant Overdose of Sodium Chloride

Michelle Hamline, MD, PhD, MAS, Georgia McGlynn, RN, MSN-CNL, CPHQ, Andrew Lee, PharmD, and JoAnne Natale, MD, PhD | May 27, 2020

Save to Library

After undergoing a complete atrioventricular canal defect repair, an infant with trisomy 21 was transferred to the pediatric intensive care unit (PICU) and total parenteral nutrition (TPN) was ordered due to low cardiac output. When the TPN order expired, it was not reordered in time for cross-checking by the dietician and pediatric pharmacist and the replacement TPN order was mistakenly entered to include sodium chloride 77 mEq/100 mL, a ten-fold higher concentration than intended. The commentary explores the safety issues with ordering TPN and custom intravenous fluids in a pediatric population, and the critical role of clinical decision support systems and the healthcare team (physicians, pharmacists, nurses and dieticians) in preventing medication-related errors.

Complications of ECMO During Transport

Mikael Broman, MD, PhD| April 29, 2020

Save to Library

A 54-year old women with chronic obstructive pulmonary disease was admitted for chronic respiratory failure. Due to severe hypoxemia, she was intubated, mechanically ventilated and required extracorporeal membrane oxygenation (ECMO). During the hospitalization, she developed clotting problems, which necessitated transfer to the operating room to change one of the ECMO components. On the way back to the intensive care unit, a piece of equipment became snagged on the elevator door and the system alarmed. The perfusionist arrived 30-minutes later and realized that the ECMO machine was introducing room air to the patient’s circulation, leading to air embolism. The patient became severely hypotensive and bradycardic, and despite aggressive attempts at resuscitation, she died.

Is that solution for IV or irrigation?: Fluid administration errors in the operating room.

Christian Bohringer, MD| March 25, 2020

Save to Library

Two patients admitted for deceased donor renal transplant surgery experienced similar near miss errors involving 1000 ml normal saline bags with 160mg gentamicin intended as bladder irrigation but mistakenly found spiked or next to the patient’s intravenous (IV) line. Confusion about using this nephrotoxic drug intravenously could result in significant harm to patients undergoing renal transplant surgery.

Think Like a Surgeon

Zara Cooper, MD, MSc| September 25, 2019

Save to Library

A man with a history of T6 paraplegia came to the emergency department with delirium, hypotension, and fever. Laboratory results revealed a high white blood cell count and mild elevation of bilirubin and liver enzymes. A stat abdominal CT showed a mildly thickened gallbladder. The patient was admitted to the intensive care unit with a provisional diagnosis of septic shock and treated with broad-spectrum antibiotics and intravenous fluids. He was transferred to the medical ward on hospital day 2, where the receiving hospitalist realized the diagnosis was still unclear. A second CT scan showed a 6 cm abscess near the liver, likely arising from a perforated gallbladder. The patient underwent an urgent open cholecystectomy and drainage of the abscess.

Pocket Syringe Swap

John C. Kulli, MD| May 1, 2011

Save to Library

A surgery fellow put two syringes in his pocket: one containing leftover anesthetic and one with agents to reverse it. When it came time to reverse the neuromuscular block, he administered the anesthetic by mistake.

Vial Mistakes Involving Heparin

Tim Vanderveen, PharmD, MS| May 1, 2009

Save to Library

Hospitalized for an elective procedure, a patient is given heparin in an incorrect concentration—off by a factor of 100.

Eptifibatide Epilogue

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

Save to Library

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.

All in the History

Christopher Fee, MD| March 21, 2009

Save to Library

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.

Failure to Latch

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

Save to Library

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.

Antiseizure Medication Disorder

Brian K. Alldredge, PharmD| May 1, 2007

Save to Library

An elderly patient with a seizure disorder (and recent admission for uncontrolled seizures) was admitted to the hospital to evaluate symptoms of lethargy, confusion, and decreased appetite. The team misattributed his mental status change to an infection but later discovered that the patient had phenytoin toxicity.

Crossed Coverage

Steven R. Kayser, PharmD| February 1, 2007

Save to Library

A woman admitted to the hospital for cardiac transplantation evaluation is mistakenly given warfarin despite an order to hold the dose due to an increase in her INR level.

Language Barrier

Glenn Flores, MD| April 1, 2006

Save to Library

With no one to interpret for them and pharmacy instructions printed only in English, nonEnglish-speaking parents give their child a 12.5-fold overdose of a medication.

Delay in Initiating Antibiotics Results in Fatal Error

Lisa M. Bellini, MD| February 1, 2004

Save to Library

Housestaff evaluate and admit a severely ill patient with lupus, suspect a viral syndrome, and do not initiate antibiotics. Despite discovery of the correct diagnosis in the morning by the attending, the patient dies.

Inadvertent Castration

J. Forrest Calland, MD| January 1, 2004

Save to Library

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.

Triage Time Bomb

Donna L. Washington, MD, MPH| January 1, 2004

Save to Library

A triage nurse instructed by a physician to immediately bring a febrile child, who was possibly dehydrated, to the treatment area is stopped by the charge nurse, citing overcrowding. The parents seek treatment elsewhere; upon arrival, the child is in full arrest.

WebM&M: Case Studies

This Month's WebM&Ms

All WebM&M: Case Studies (17)

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

WebM&M: Case Studies

This Month's WebM&Ms

All WebM&M: Case Studies (17)

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users