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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: May 16, 2022
Garima Agrawal, MD, MPH, and Mithu Molla, MD, MBA | May 16, 2022

This WebM&M describes two cases involving patients who became unresponsive in unconventional locations – inside of a computed tomography (CT) scanner and at an outpatient transplant clinic – and strategies to ensure that all healthcare teams are... Read More

Alexandria DePew, MSN, RN, James Rice, & Julie Chou, BSN | May 16, 2022

This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary... 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 (125)

Published Date
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1 - 20 of 125 WebM&M Case Studies
Alexandria DePew, MSN, RN, James Rice, & Julie Chou, BSN | May 16, 2022

This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.

Robin Aldwinckle, MD and Edmund Florendo, MD| October 27, 2021

A 78-year-old woman with macular degeneration presented for a pars plana vitrectomy (PPV) under monitored anesthesia care (MAC) with an eye block. At this particular hospital, eye cases under MAC are typically performed with an eye block by the surgeon after the anesthesiologist has administered some short-acting sedation, commonly with remifentanil. On this day, there was a shortage of premixed remifentanil and the resident – who was unfamiliar with the process of drug dilution – incorrectly diluted the remifentanil solution. Shortly after receiving sedation, the patient became unresponsive, and a code was called. The commentary addresses the challenges of drug dilution and strategies to reduce dilutional errors and prioritize patient safety.

Florence Tan, PharmD, Karnjit Johl, MD and Mariya Kotova, PharmD| September 29, 2021

This case describes multiple emergency department (ED) encounters and hospitalizations experienced by a middle-aged woman with sickle cell crisis and a past history of multiple, long admissions related to her sickle cell disease. The multiple encounters highlight the challenges of opioid prescribing for patients with chronic, non-cancer pain. The commentary discusses the limitations of prescription drug monitoring program (PDMP) data for patients with chronic pain, challenges in opioid dose conversions, and increasing patient safety through safe medication prescribing and thorough medication reconciliation.

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Jeremiah Duby, PharmD, Kendra Schomer, PharmD, Victoria Oyewole, PharmD, Delia Christian, RN, BSN, CNRN, and Sierra Young, PharmD| May 26, 2021

A 65-year-old man with a history of type 2 diabetes mellitus, hypertension, and coronary artery disease was transferred from a Level III trauma center to a Level I trauma center with lower extremity paralysis after a ground level fall complicated by a 9-cm abdominal aortic aneurysm and cervical spinal cord injury. Post transfer, the patient was noted to have rapidly progressive ascending paralysis. Magnetic resonance imaging (MRI) revealed severe spinal stenosis involving C3-4 and post-traumatic cord edema/contusion involving C6-7. A continuous intravenous (IV) infusion of norepinephrine was initiated to maintain adequate spinal cord perfusion, with a target mean arterial pressure goal of greater than 85 mmHg. Unfortunately, norepinephrine was incorrectly programmed into the infusion pump for a weight-based dose of 0.5 mcg/kg/min rather than the ordered dose of 0.5 mcg/min, resulting in a dose that was 70 times greater than intended. The patient experienced bradycardia and cardiac arrest and subsequently died.

Two separate patients undergoing urogynecologic procedures were discharged from the hospital with vaginal packing unintentionally left in the vagina. Both cases are representative of the challenges of identifying and preventing retained orifice packing, the critical role of clear handoff communication, and the need for organizational cultures which encourage health care providers to communicate and collaborate with each other to optimize patient safety.

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Wesley Valdes, DO and Garth Utter, MD, MSc | March 31, 2021

A 71-year-old frail, non-ambulatory woman presented to the emergency department with fever, sweating and dry cough. Her work-up included non-specific evidence of infection but two negative COVID-19 tests. No source of infection was identified, and she was discharged home after three days. During a video visit with her primary care provider the next day, the patient noted worsening symptoms as well as a skin breakdown on her “backside”; however, no rectal or genital exams were completed during her inpatient stay and the physician did not visualize the area during the video visit. The patient was readmitted to the hospital two days later in septic shock due to a necrotizing soft tissue infection related to a perirectal abscess. The commentary discusses the need for a broad differential diagnosis in seriously ill patients, the influence of diagnostic biases during a pandemic, and how to address perceived limitations in the ability to examine patients in the setting of virtual care.

Berit Bagley, MSN, Dahlia Zuidema, PharmD, Stephanie Crossen, MD, and Lindsey Loomba, MD | October 28, 2020

A 14-year-old girl with type 1 diabetes (T1D) was admitted to the hospital after two weeks of heavy menstrual bleeding as well as blurred vision, headache and left arm numbness. MRI revealed an acute right middle cerebral artery (MCA) infarct. Further evaluation led to a diagnosis of antiphospholipid syndrome. The patient was persistently hyperglycemic despite glycemic management using her home insulin pump and continuous glucose monitor. Over the course of her hospitalization, her upper extremity symptoms worsened, and she developed upper extremity, chest, and facial paresthesia. Imaging studies revealed new right MCA territory infarcts as well as splenic and bilateral infarcts. The case describes how suboptimal inpatient management of diabetes technology contributed to persistent hyperglycemia in the setting of an acute infarction. The commentary discusses best practices for optimizing patient safety when managing hospitalized patients on home insulin pumps. 

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Kristine Chin, PharmD, Van Chau, PharmD, Hannah Spero, MSN, APRN, and Jessamyn Phillips, DNP | September 30, 2020

This case involves a 65-year-old woman with ongoing nausea and vomiting after an uncomplicated hernia repair who was mistakenly prescribed topiramate (brand name Topamax, an anticonvulsant and nerve pain medication) instead of trimethobenzamide (brand name Tigan, an antiemetic) by the outpatient pharmacy. The commentary uses the Swiss Cheese Model to discuss the safety challenges of “look-alike, sound-alike” (LASA) medications, the importance of phyiscians employing “soft” skills during medication dispensing, and how medication administration errors can occur in outpatient pharmacy settings, despite multiple opportunities for cross-verification. 

Amparo C. Villablanca, MD, and Gordon X. Wong, MD, MBA | July 29, 2020

A 52-year-old woman with a known history of coronary artery disease and ischemic cardiomyopathy was admitted for presumed community-acquired pneumonia. The inpatient medicine team obtained a “curbside” cardiology consultation which concluded that the worsening left ventricular systolic functioning was in the setting of acute pulmonary edema. Two months post-discharge, a nuclear stress test was suggestive of infarction and a subsequent catheterization showed a 100% occlusion. The commentary discusses cardiovascular-related diagnostic errors affecting women and the advantages, pitfalls and best practices for curbside consultations in acute care settings.

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Daniel D. Nguyen, PharmD, Thomas A. Harper, MPH, CPhT, FCSHP and Ryan Cello, PharmD | July 29, 2020

A patient was mistakenly administered intravenous fentanyl which was leftover from a previous patient and not immediately wasted. Experts recommend the best practice for the safe disposal, or “waste”, of medications in the surgical setting is to either waste any leftover product immediately after administration or to fully document all waste at the end of the case.This commentary discusses the policies and procedures addressing wasting of medication by anesthesiologists, approaches to reduce medication administration errors, and the importance identifying process gaps that could lead to potential diversion.  

Janeane Giannini, PharmD, Melinda Wong, PharmD, William Dager, PharmD, Scott MacDonald, MD, and Richard H. White, MD | June 24, 2020
A male patient with history of femoral bypasses underwent thrombolysis and thrombectomy for a popliteal artery occlusion. An error in the discharge education materials resulted in the patient taking incorrect doses of rivaroxaban post-discharge, resulting in a readmission for recurrent right popliteal and posterior tibial occlusion. The commentary discusses the challenges associated with prescribing direct-action oral anticoagulants (DOACs) and how computerized clinical decision support tools can promote adherence to guideline recommendations and mitigate the risk of error, and how tools such as standardized teaching materials and teach-back can support patient understanding of medication-related instructions.
Christopher Chen, MD and Sandhya Venugopal, MD, MS-HPEd| March 25, 2020
The patient safety committee at a large tertiary care hospital received nine incident reports within three months involving electrocardiogram (EKG) reports that were uploaded into the wrong patients’ chart. All of these events were due to users failing to clear the previous patient’s information from, and/or users failing to enter the new patient’s information into, the EKG machine when obtaining an EKG.
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.
Lamia S. Choudhury, MS1 and Catherine T Vu, MD| January 29, 2020
Multiple patients were admitted to a large tertiary hospital within a 4-week period and experienced patient identification errors. These cases highlight important systems issues contributing to this problem and the consequences of incorrect patient identification.
A 74-year-old male with a history of hypertension, hyperlipidemia, paroxysmal atrial fibrillation, coronary artery disease, congestive heart failure with an EF of 45%, stage I chronic kidney disease and gout presented for a total hip replacement. He had multiple home medications and was also on Warfarin, which was held appropriately prior to the surgery.  A Type and Cross for blood request was sent along with baseline labs; however, there was a mislabeling error on one of the samples causing a delay in the blood getting to the operating room resulting in the medical team initiating a massive transfusion protocol when the patient became hypotensive.
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Adrianne M Widaman, PhD, RD | December 18, 2019
A 62-year-old man with a history of malnutrition-related encephalopathy was admitted for possible aspiration pneumonia complicated by empyema and coagulopathy. During the hospitalization, he was uncooperative and exhibited signs of delirium. For a variety of reasons, he spent two weeks in the hospital with minimal oral intake and without receiving most of his oral medications, putting him at risk for complications and adverse outcomes.
Erika Cutler, PharmD, and Delani Gunawardena, MD | December 18, 2019
A 55-year-old man visited his oncologist for a follow-up appointment after completing chemotherapy and reported feeling well with his abdominal and bony pain well controlled with opioid therapy.  At the end of the visit, his oncologist reordered his pain medication and, due to a best practice alert, also prescribed naloxone but failed to provide any instruction on its use. Later that day, the patient took the naloxone along with his opioid pain medication and within a minute experienced severe abdominal and bony pain, requiring admission to the emergency department.
Adam Wright, PhD, and Gordon Schiff, MD| October 30, 2019
Following resection of colorectal cancer, a hospitalized elderly man experienced a pulmonary embolism, which was treated with rivaroxaban. Upon discharge home, he received two separate prescriptions for rivaroxaban (per protocol): one for 15 mg twice daily for 10 days, and then 20 mg daily after that. Ten days later, the patient's wife returned to the pharmacy requesting a refill. On re-reviewing the medications with her, the pharmacist discovered the patient had been taking both prescriptions (a total daily dose of 50 mg daily). This overdose placed him at very high risk for bleeding complications.
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Tobias Dreischulte, MPharm, MSc, PhD| July 2, 2019
During a primary care visit, a woman with morbid obesity, chronic obstructive pulmonary disease, hypertension, heart failure, and diabetes mellitus complained of worsening lower extremity edema over the past few weeks. Her physician prescribed a thiazide diuretic. The patient presented to the emergency department (ED) 10 days later with 3 days of drowsiness and confusion. Laboratory results revealed severe hyponatremia and hypokalemia. She had a seizure in the ED and was admitted to the intensive care unit. Both the critical care provider and a nephrologist felt the diuretic had caused the electrolyte abnormalities.
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