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: November 30, 2023

New

When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!

Berit Bagley, RN, MSN, CDCES, BC-ADM, Charity L. Tan, MSN, ACNP-BC, CDCES, BC-ADM, Deborah Plante, MD | November 30, 2023

A 67-year-old man with well-controlled type 2 diabetes mellitus underwent elective cardiac... Read More

New

Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon

Christian Bohringer, MBBS, and Sharon Ashley, MD | November 30, 2023

A 38-year-old woman with class 3 obesity required removed of a gastric balloon under general anesthesia.... Read More

New

Medication Mix-Up Leads to Patient Death

Luciano Sanchez, PharmD and Patrick Romano, MD, MPH | November 30, 2023

An 81-year-old man was admitted to the intensive care unit (ICU) with a gastrointestinal bleed and referred for a diagnostic colonoscopy. The nurse preparing... Read More

Spotlight Case

CE/MOC

New

The Risks of a Malpositioned Gastrostomy Tube and Poor Communication

Rachel Ann Hight, MD, FACS | November 29, 2023

This case describes a 55-year-old woman who sustained critical injuries after a motor vehicle crash and had a lengthy... Read More

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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 (17)

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Prolonged DKA in Pregnancy: A Case of Communication Breakdown.

Sarah Marshall, MD and Nina M. Boe, MD| August 30, 2023

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A 31-year-old pregnant patient with type 1 diabetes on an insulin pump was hospitalized for euglycemic diabetic ketoacidosis (DKA). She was treated for dehydration and vomiting, but not aggressively enough, and her metabolic acidosis worsened over several days. The primary team hesitated to prescribe medications safe in pregnancy and delayed reaching out to the Maternal Fetal Medicine (MFM) consultant, who made recommendations but did not ensure that the primary team received and understood the information. The commentary highlights how breakdowns in communication amongst providers can lead to medical errors and prolonged hospitalization and how the principles of team-based care, communication, and a culture of safety can improve care in complex health care situations.

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Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To?

Tanya Rinderknecht, MD and Garth Utter MD, MSc| April 29, 2020

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A 52-year old women presented to the emergency department with a necrotizing soft tissue infection (necrotizing fasciitis) after undergoing cosmetic abdominoplasty (‘tummy tuck’) elsewhere. A lack of communication and disputes between the Emergency Medicine, Emergency General Surgery and Plastic Surgery teams about what service was responsible for the patient’s care led to delays in treatment. These delays allowed the infection to progress, ultimately requiring excision of a large area of skin and soft tissue.

The Safety Challenges of Supervision and Night Coverage in Academic Residency

Katie Raffel, MD| October 30, 2019

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An intern night float, called in on jeopardy from an outside institution for an intern who was ill, was paged to the bedside of an unstable patient to assess his condition. In the electronic health record, the intern checked the code status and clinical information, but the signout did not specify the patient’s goals of care nor what course of action to take should the patient worsen. Although the patient was listed as full code and the intern attempted to reach both the rapid response team and the senior resident, she was not aware the pager numbers were incorrect. Eventually, the intern flagged a senior resident passing in the hallway, who assessed the patient and suggested they contact his family.

Spotlight: Mistaken Attribution, Diagnostic Misstep

Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD| January 1, 2019

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A woman with a history of psychiatric illness presented to the emergency department with agitation, hallucinations, tachycardia, and transient hypoxia. The consulting psychiatric resident attributed the tachycardia and hypoxia to her underlying agitation and admitted her to an inpatient psychiatric facility. Over the next few days, her tachycardia persisted and continued to be attributed to her psychiatric disease. On hospital day 5, the patient was found unresponsive and febrile, with worsening tachycardia, tachypnea, and hypoxia; she had diffuse myoclonus and increased muscle tone. She was transferred to the ICU of the hospital, where a chest CT scan revealed bilateral pulmonary emboli (explaining the tachycardia and hypoxia), and clinicians also diagnosed neuroleptic malignant syndrome (a rare and life-threatening reaction to some psychiatric medications).

The Forgotten Line

Marta L. Render, MD| May 1, 2012

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After placing a central line in an elderly patient following a heart attack, a community hospital transferred him to a referral hospital for stenting of his coronary arteries. He was discharged to an assisted living facility 2 days later, with the central line still in place.

The Safety and Quality of Long Term Care

Amy A. Vogelsmeier, PhD, RN| September 1, 2011

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Following surgical repair for a hip fracture, a nursing home resident with limited mobility developed a fever. She was readmitted to the hospital, where examination revealed a very deep pressure ulcer. Despite maximal efforts, the patient developed septic shock and died.

Reconciling Records

Hardeep Singh, MD, MPH; Dean F. Sittig, PhD; Maureen Layden, MD, MPH| November 1, 2010

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At two different hospitals, patients were instructed to continue home medications, even though their medication lists had errors that could have led to significant adverse consequences.

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.

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.

Moving Pains

Hildy Schell, RN, MS, CCNS; Robert M. Wachter, MD| July 1, 2006

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An elderly woman was transported to CT with no medical escort and an inadequate oxygen supply. She died later that day.

Lost in Transition

Christopher Beach, MD| February 1, 2006

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A woman comes to the ED with mental status changes. Although numerous tests are run and she is admitted, a critical test result fails to reach the medicine team in time to save the patient's life.

Do Me a Favor

Ann Williamson, PhD, RN| May 1, 2004

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An antenatal room left in disarray causes a charge nurse to search for the missing patient. Investigation reveals that a resident had performed an ultrasound on a nurse friend rather than a true "patient."

Fumbled Handoff

Arpana Vidyarthi, MD| March 1, 2004

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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.

Delay in Initiating Antibiotics Results in Fatal Error

Lisa M. Bellini, MD| February 1, 2004

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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.

40 of K

Timothy S. Lesar, PharmD| November 1, 2003

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An unclear verbal order leads to administration of the wrong drug.

To LP or Not LP

Christopher P. Landrigan, MD, MPH| October 1, 2003

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An infant sent to the ED for an LP is mistakenly redirected to the lab for a "blood test"; hours later, at a second ED, he is found to have meningitis.

WebM&M: Case Studies

This Month's WebM&Ms

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