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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: December 14, 2022
Narath Carlile, MD, MPH, Clyde Lanford Smith, MD, MPH, DTM&H, James H. Maguire, MD, and Gordon D. Schiff, MD | December 14, 2022

This case describes a man in his 70s with a history of multiple myeloma and multiple healthcare encounters for diarrhea in the previous five years, which had always been attributed to viral or unknown causes, without any microbiologic or serologic... Read More

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Naileshni S. Singh, MD | December 14, 2022

A 63-year-old woman was admitted to a hospital for anterior cervical discectomy (levels C4-C7) and plating for cervical spinal stenosis under general anesthesia. The operation was uneventful and intraoperative neuromonitoring was used to help prevent... Read More

Mark Fedyk, PhD, Nathan Fairman, MD, MPH, Patrick S. Romano, MD, MPH, John MacMillan, MD, and Monica Miller, RN, MS, CCRN | December 14, 2022

A 65-year-old man with metastatic liver disease presented to the hospital with worsening abdominal pain after a partial hepatectomy and development of a large ventral hernia. Imaging studies revealed perforated diverticulitis. A goals-of-care... 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 (8)

Displaying 1 - 8 of 8 WebM&M Case Studies

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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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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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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After an emergency department (ED) physician interpreted results of a point-of-care ultrasound as showing stable low ejection fraction, some volume overload, and a mechanical mitral valve in place without regurgitation for a man with a history of congestive heart failure, end-stage renal disease, and mechanical mitral valve replacement who presented with shortness of breath, the patient was admitted with a presumed diagnosis of volume overload. Reassured by the ED physician's interpretation of the ultrasound, the hospitalist ordered no further cardiac testing. The patient underwent hemodialysis, felt better, and was discharged. Less than 12 hours later, the patient returned critically ill and in cardiogenic shock. An emergency transthoracic echocardiogram found a thrombosed mitral valve, which had led to acute mitral stenosis and cardiogenic shock.
Urmimala Sarkar, MD, MPH| October 1, 2013
Although the mother of a child, born male who identified as and expressed externally as a girl, had alerted the clinic of the child's preferred name when making the appointment, the medical staff called for the patient in the waiting room using her legal (masculine) name.
Ted Eytan, MD, MS, MPH| October 1, 2008
An elderly, non–English-speaking man with diabetes was admitted to the hospital twice in 8 days due to hypoglycemia. At discharge, the patient was instructed not to take any antidiabetic medications. In between hospitalizations, he saw his primary care physician, who restarted an antidiabetic medication.
Nils Kucher, MD| January 1, 2006
Following reconstructive surgery to her hand, a woman suffers sudden cardiopulmonary arrest. After successful resuscitation, further review revealed that she had a pulmonary embolism and that she had received no venous thromboembolism prophylaxis.
Jeremy P. Feldman, MD; Michael K. Gould, MD, MS | March 1, 2004
A central line placed incorrectly causes a patient to suffer permanent neurologic damage.