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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 5, 2022
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 (24)

1 - 20 of 24 WebM&M Case Studies
Nam K Tran, PhD, HCLD (ABB), FAACC and Ying Liu, MD| February 26, 2020
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.
Casey A. Cable, MD; David J. Murphy, MD, PhD; and Greg S. Martin, MD, MSc| September 1, 2017
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.
Sarah Doernberg, MD, MAS| July 1, 2017
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.
Jonathan R. Genzen, MD, PhD, and Heather N. Signorelli, DO| March 1, 2015
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.
Jeanne M. Farnan, MD, MHPE; and Vineet M. Arora, MD, MAPP| May 1, 2012
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.
Vanitha Janakiraman Mohta, MD| February 1, 2012
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.
Eugene Litvak, PhD, and Sarah A. Bernheim| November 1, 2011
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.
Chase Coffey, MD, MS| November 1, 2010
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.
Nita S. Kulkarni, MD; Mark V. Williams, MD| May 1, 2008
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.
Debra Gerardi, RN, MPH, JD| December 1, 2007
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.
F. Daniel Duffy, MD; Christine K. Cassel, MD| October 1, 2007
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.
Bruce D. Adams, MD| October 1, 2007
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.
Pascale Carayon, PhD| May 1, 2007
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.
B. Joseph Guglielmo, PharmD| March 1, 2007
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.
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.
Robert L. Wears, MD, MS| September 1, 2004
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.
Bradley A. Sharpe, MD| July 1, 2004
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.
Michael Astion, MD, PhD| June 1, 2004
Just before leaving for the weekend, a physician orders a test for a communicable infection. Although the result arrives and isolation signs are placed on the patient's door, none of the covering physicians are notified, and the float nurses mistakenly assume the patient is already receiving treatment.
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.