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: March 15, 2023

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Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation

Jonathan Trask, RN, Kathleen M. Carlsen, PA, Brooks T. Kuhn, MD | March 15, 2023

A 72-year-old man was diagnosed with COVID-19 pneumonia and ileus, and admitted to a specialized COVID care unit. A nasogastric tube (NGT) was placed, supplemental oxygen was provided, and oral feedings were... Read More

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Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists

Lucy Shi, MD and Erik Noren MD, MS | March 15, 2023

A 71-year-old man presented to his physician with rectal bleeding and pain, which was attributed to radiation proctitis following therapy for adenocarcinoma of the prostate. He subsequently developed a potentially life... Read More

New

Medication Handling and Compounding Errors in the Operating Room.

Joy Chaudhry, PharmD, BCPS, BCCCP, Julie Chou BSN, RN, CNOR, Courtney Manning, PharmD, MBA, Minji Kim, RN, BSN, CNOR, and David Dakwa, PharmD, MBA, BCPS, BCSCP | March 15, 2023

This case focuses on immediate-use medication compounding in the operating room and how the process creates situations in which medication errors can occur. The commentary discusses strategies for safe perioperative compounding and the... Read More

New

Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm.

Christian Bohringer, MD | March 15, 2023

A 48-year-old woman was placed under general anesthesia with a laryngeal mask. The anesthesiologist was distracted briefly to sign for opioid drugs in a register, and during this time,... Read More

New

Duplicate Therapies in Retail Pharmacy

Nisha Punatar, MD, Samson Lee, PharmD, BCACP, and Mithu Molla, MD, MBA | March 15, 2023

The cases described in this WebM&M reflect fragmented care with lapses in coordination and communication as well as failure to appropriately address medication discrepancies. These two cases involve duplicate therapy errors, which have the potential to cause... 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.

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All WebM&M: Case Studies (27)

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Displaying 1 - 20 of 27 WebM&M Case Studies

Pre-analytical pitfalls: Missing and mislabeled specimens

Nam K Tran, PhD, HCLD (ABB), FAACC and Ying Liu, MD| February 26, 2020

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This commentary involves two separate patients; one with a missing lab specimen and one with a mislabeled specimen. Both cases are representative of the challenges in obtaining and appropriately tracking lab specimens and the potential harms to patients. The commentary describes best practices in managing lab specimens.

Failed Interpretation of Screening Tool: Delayed Treatment

Casey A. Cable, MD; David J. Murphy, MD, PhD; and Greg S. Martin, MD, MSc| September 1, 2017

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For an older patient presenting with upper back pain and faint bilateral crackles, physicians misinterpreted a negative sepsis screen as a negative infection screen and delayed antibiotic treatment for pneumonia. The patient developed worsened hypoxemia, hypotension, delirium, and progressive organ failure.

Delayed Recognition of a Positive Blood Culture

Sarah Doernberg, MD, MAS| July 1, 2017

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A woman was discharged with instructions to complete an antibiotic course for C. difficile. The same day, the microbiology laboratory notified the patient's nurse that her blood culture grew Listeria monocytogenes, a bacterium that can cause life-threatening infection. However, the result was not communicated to the medical team prior to discharge.

Critical Opportunity Lost

Jonathan R. Genzen, MD, PhD, and Heather N. Signorelli, DO| March 1, 2015

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After presenting to the emergency department, a woman with chest pain was given nitroglycerine and a so-called GI cocktail. Her electrocardiogram was unremarkable, and she was scheduled for a stress test the next morning. A few minutes into the stress test, the patient collapsed and went into cardiac arrest.

The Perils of Cross Coverage

Jeanne M. Farnan, MD, MHPE; and Vineet M. Arora, MD, MAPP| May 1, 2012

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Inadequate signout to the members of the night float team prevented them from appreciating a patient's mental status changes. Found comatose by the weekend cross-coverage team, the patient had a prolonged ICU stay.

Amended Lab Results: Communication Slip

Vanitha Janakiraman Mohta, MD| February 1, 2012

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A pregnant woman with new onset hypertension and proteinuria was admitted to the hospital for further testing. Test results for a 24-hour urine collection were initially reported as normal in the electronic medical record, and discharge planning was begun. However, a later amended report showed the results were elevated and abnormal, confirming a diagnosis of preeclampsia.

The Case for Patient Flow Management

Eugene Litvak, PhD, and Sarah A. Bernheim| November 1, 2011

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Following hospitalization for suicidality, a woman was discharged to the care of her outpatient psychiatrist, a senior resident who was about to graduate. At her last visit in June before the year-end transfer, the patient was unable to schedule a follow-up visit because the new residents' schedules were not yet in the system. The delay in care had deadly consequences.

A Seasonal Care Transition Failure

John Q. Young, MD, MPP| July 1, 2011

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A healthy elderly man presented to his primary care doctor—a third-year internal medicine resident—for routine examination. A PSA test was markedly elevated, but the results came back after the resident had graduated, and the alert went unread. Months later, the patient presented with new onset low back pain and was diagnosed with metastatic prostate cancer.

Treatment Challenges After Discharge

Chase Coffey, MD, MS| November 1, 2010

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A man returns to the emergency department 11 days after hospital discharge in worsening condition. With no follow-up on a urine culture and sensitivity sent during his hospitalization, the patient had been taking the wrong antibiotic for a UTI.

Is It Safe to Be Direct?

Nita S. Kulkarni, MD; Mark V. Williams, MD| May 1, 2008

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An elderly patient seen in his primary care physician's office was stable but had a suspected heart failure exacerbation. The PCP chose to admit the patient directly to the hospital, to avoid a long emergency department stay. While in the admitting office awaiting an available bed, the patient deteriorated.

Elopement

Debra Gerardi, RN, MPH, JD| December 1, 2007

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An inpatient missing from his room is found several hours later outside the emergency department. Despite having arrived at the ED in a hospital gown with an inpatient ID bracelet, the patient is treated in the ED and discharged.

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.

Code Blue—Where To?

Bruce D. Adams, MD| October 1, 2007

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A code blue is called on an elderly man with a history of coronary artery disease, hypertension, and schizophrenia hospitalized on the inpatient psychiatry service. Housestaff covering the code team did not know where the service was located, and when the team arrived, they found their equipment to be incompatible with the leads on the patient.

Production Pressures

Pascale Carayon, PhD| May 1, 2007

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On the day of a patient's scheduled electroconvulsive therapy, the clinic anesthesiologist called in sick. Unprepared for such an absence, the staff asked the very busy OR anesthesiologist to fill in on the case. Because the wrong drug was administered, the patient did not wake up as quickly as expected.

Staggered Sensitivity Results

B. Joseph Guglielmo, PharmD| March 1, 2007

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Several days after a patient’s surgery, preliminary wound cultures grew Staphylococcus aureus. Although the final sensitivity profile for the cultures showed resistance to the antibiotic that the patient was receiving, the care team was not notified and the patient died of sepsis.

Right Patient, Wrong Sample

Michael Astion, MD, PhD | December 1, 2006

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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.

Workaround Error

Tess Pape, PhD, RN, CNOR| February 1, 2006

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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.

An Outpatient 'Zebra'

Lee Berkowitz, MD| January 1, 2006

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Over several weeks, a man with left foot pain and numbness is evaluated by numerous doctors, each resident and attending pair offering a different incorrect diagnosis until the patient's fourth visit.

Caution, Interrupted

Robert L. Wears, MD, MS| September 1, 2004

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A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and winds up hanging the bag anyway.

Glucose Roller Coaster

Bradley A. Sharpe, MD| July 1, 2004

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A woman hospitalized for CHF (with no history of diabetes) is given several rounds of insulin and D50, after repeated blood tests show her glucose to be dangerously high, then dangerously low. Turns out, the blood samples were drawn incorrectly and the signouts were incomplete.

WebM&M: Case Studies

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