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

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

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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.

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All WebM&M: Case Studies (29)

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Displaying 1 - 20 of 29 WebM&M Case Studies

Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy

Kevin J. Kelly, MD | August 31, 2022

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A 65-year-old female with a documented allergy to latex underwent surgery for right-sided Zenker’s diverticulum. Near the conclusion of surgery, a latex Penrose drain was placed in the neck surgical incision. The patient developed generalized urticaria, bronchospasm requiring high airway pressures to achieve adequate ventilation, and hypotension within 5 minutes of placement of the drain. The drain was removed and replaced with a silicone drain. Epinephrine and vasopressors were administered post-operatively and the patient’s symptoms resolved. The commentary discusses risk factors and consequences of latex allergy in hospital and operating room settings, common latex products that trigger allergic reactions and hospital safety practices that can limit the risk of latex exposure.

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When the Indications for Drug Administration Blur

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

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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.

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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.

What Happened on Telemetry?

by Kristin E. Sandau, PhD, RN, and Marjorie Funk, PhD, RN| April 1, 2019

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An elderly woman with a history of dementia, chronic obstructive pulmonary disease, hypertension, and congestive heart failure (CHF) was brought to the emergency department and found to meet criteria for sepsis. Due to her CHF, she was admitted to a unit with telemetry monitoring, which at this institution was performed remotely. When the nurse came to check the patient's vital signs several hours later, she found the patient to be unresponsive and apneic, with no palpable pulse. A Code Blue was called, but the patient died. Although the telemetry technician had recognized progressive bradycardia and called the hospital floor several minutes before the code, he was placed on hold because the nurse was busy with another patient. While he was holding, he observed worsening bradycardia, eventually transitioning to asystole, and tried to redial the unit, but no one answered.

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.

Outbreak

Richard Rothman, MD, PhD; Sahael Stapleton, MD| May 1, 2011

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An emergency department worker develops chicken pox following an exposure during one of his shifts.

Failure to Reevaluate

Annie Wong-Beringer, PharmD| December 1, 2010

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A patient on palliative chemotherapy was given intravenous vancomycin for methicillin-resistant staphylococcus aureus (MRSA), despite a rising creatinine level, and went into acute kidney failure.

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.

Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care

Victoria Rich, PhD, RN| August 1, 2009

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Admitted to the ICU for COPD exacerbation and atrial fibrillation, a patient who had stabilized is left unattended in the bathroom while the nurse on an understaffed unit attends to a more emergent patient. An assistant later finds the patient on the floor, unresponsive and cyanotic.

Is the Admission Drug Dose Too Low?

Rainu Kaushal, MD, MPH; Erika Abramson, MD | August 1, 2009

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The theophylline dose of a patient admitted for COPD exacerbation and pneumonia is doubled, and he develops atrial flutter with a rapid ventricular response, chest pain, and increased shortness of breath.

Wrong Route for Nutrients

Jill R. Scott-Cawiezell, RN, PhD| July 1, 2008

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An elderly man receiving feedings through a percutaneous enterostomy tube was prescribed intravenous total parenteral nutrition (TPN). A licensed practical nurse (LPN) mistakenly connected the TPN to the patient's enterostomy tube. His daughter (a retired nurse) asked her about it, and the RN on duty confirmed the error. The LPN disconnected the mistakenly placed (and now contaminated) line, but then prepared to attach it to the intravenous catheter. Luckily, both the patient's daughter and the RN were present and stopped her.

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.

WebM&M: Case Studies

This Month's WebM&Ms

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