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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 31, 2022
Commentary by Jennifer Rosenthal, MD, MAS and Michelle Hamline, MD, PhD, MAS | August 31, 2022

A 2-year-old girl presented to her pediatrician with a cough, runny nose, low grade fever and fatigue; a nasal swab for SARS-CoV-2 and influenza was negative and lung sounds were clear. The patient developed a fever and labored breathing and was... Read More

Spotlight Case
CE/MOC
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Anamaria Robles, MD, and Garth Utter, MD, MSc | August 31, 2022

A 49-year-old woman was referred by per primary care physician (PCP) to a gastroenterologist for recurrent bouts of abdominal pain, occasional vomiting, and diarrhea. Colonoscopy, esophagogastroduodenoscopy, and x-rays were interpreted as normal, and... Read More

Take the Quiz
Samantha Brown, MD, John S. Rose, MD, and David K. Barnes, MD | August 31, 2022

A 71-year-old man presented to a hospital-based orthopedic surgery clinic for a follow-up evaluation of his knee and complaints of pain and swelling in his right shoulder. His shoulder joint was found to be acutely inflamed and purulent fluid was... Read More

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 (31)

1 - 20 of 31 WebM&M Case Studies
By Gary S. Leiserowitz, MD, MS and Herman Hedriana, MD| November 25, 2020

After a failed induction at 36 weeks, a 26-year-old woman underwent cesarean delivery which was complicated by significant postpartum hemorrhage. The next day, the patient complained of severe perineal and abdominal pain, which the obstetric team attributed to prolonged pushing during labor. The team was primarily concerned about hypotension, which was thought to be due to hypovolemia from peri-operative blood loss. After several hours, the patient was transferred to the medical intensive care unit (ICU) with persistent hypotension and severe abdominal and perineal pain. She underwent surgery for suspected necrotizing fasciitis, but necrosis was not found. The patient returned to the surgical ICU but deteriorated; she returned to the operating room, where she was found to have necrotizing soft tissue infection, including in the flanks, labia, and uterus. She underwent extensive surgery followed by a lengthy hospital stay. The accompanying commentary discusses the contribution of knowledge deficits and cognitive biases to diagnostic errors and the importance of structured communications between professionals.

Tanya Rinderknecht, MD and Garth Utter MD, MSc| April 29, 2020
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.
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.
Audrey Lyndon, PhD, RN, and Stephanie Lim, MD| June 1, 2019
During surgery for a forearm fracture, a woman experienced a drop in heart rate to below 50 beats per minute. As the consultant anesthesiologist had stepped out to care for another patient, the resident asked the technician to draw up atropine for the patient. When the technician returned with an unlabeled syringe without the medication vial, the resident was reluctant to administer the medication, but did so without a double check after the technician insisted it was atropine. Over the next few minutes, the patient's blood pressure spiked to 250/135 mm Hg.
Emanuel Kanal, MD| May 1, 2019
After presenting with new left-sided weakness and hypertensive urgency, a woman was admitted to the stroke unit, and the consulting neurologist ordered an urgent MRI of the brain. Although the patient required pushes of intravenous hypertensive medication to control her blood pressure (BP), she was taken to radiology where the nurse checked her BP one more time before leaving her in the MRI machine with the BP cuff still on. Within a few seconds of starting the scan, the patient's arm with the BP cuff was sucked into the MRI scanner, making a loud noise.
Stephanie Rogers, MD, and Derek Ward, MD| April 1, 2019
An elderly man with a complicated medical history slipped on a rug at home, fell, and injured his hip. Emergency department evaluation and imaging revealed no head injury and a left intertrochanteric hip fracture. Although he was admitted to the orthopedic surgery service, with surgery to fix the fracture initially scheduled for the next day, the operation was delayed by 3 days due to several emergent trauma cases and lack of surgeon availability. He ultimately underwent surgery and was discharged a few days later but was readmitted several weeks later with chest pain and shortness of breath. He was found to have a pulmonary embolism; anticoagulation was initiated. The patient's rehabilitation was delayed, his recovery was prolonged, and he never returned to his baseline functional status.
Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD| January 1, 2019
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).
Mark W. Scerbo, PhD, and Alfred Z. Abuhamad, MD| January 1, 2015
A woman who had an uncomplicated pregnancy and normal labor with no apparent signs of distress delivered a cyanotic, flaccid infant requiring extensive resuscitation. Although fetal heart rate tracings had shown signs of moderate-to-severe fetal distress for 90 minutes prior to delivery, clinicians did not notice the abnormalities on the remote centralized monitor, which displayed 16 windows, each for a different patient.
Marta L. Render, MD| May 1, 2012
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.
Amy A. Vogelsmeier, PhD, RN| September 1, 2011
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.
Hardeep Singh, MD, MPH; Dean F. Sittig, PhD; Maureen Layden, MD, MPH| November 1, 2010
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.
Hedy Cohen, RN, BSN, MS| March 21, 2009
New medication administration policies at one hospital cause a patient to receive two doses of her daily medication within a few hours, when only one dose was intended.
Jill R. Scott-Cawiezell, RN, PhD| July 1, 2008
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.
David L. Feldman, MD, MBA| May 1, 2008
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.
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.
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.
Patrice L. Spath, BA, RHIT| March 1, 2007
An infant receives an overdose of the wrong antibiotic (cephazolin instead of ceftriaxone). The nurse spoke with the ED physician on duty but was informed that the medications were essentially equivalent and did not report the error.
Mary A. Blegen, PhD, RN; Ginette A. Pepper, PhD, RN| May 1, 2006
A nursing student administers the wrong 'cup' of medications to an elderly man. A different student discovered the error when she reviewed the medicines in her patient's cup and noticed they were the wrong ones.
Christopher Beach, MD| February 1, 2006
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.