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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: March 15, 2023
New
Medication Handling and Compounding Errors in the Operating Room.
Joy Chaudhry, PharmD, BCPS, BCCCP, Julie Chou BSN, RN, CNOR, Courtney Manning, PharmD, MBA, Minji Kim, RN, BSN, CNOR, and David Dakwa, PharmD, MBA, BCPS, BCSCP | March 15, 2023

This case focuses on immediate-use medication compounding in the operating room and how the process creates situations in which medication errors can occur. The commentary discusses strategies for safe perioperative compounding and the... Read More

New
Duplicate Therapies in Retail Pharmacy
Nisha Punatar, MD, Samson Lee, PharmD, BCACP, and Mithu Molla, MD, MBA | March 15, 2023

The cases described in this WebM&M reflect fragmented care with lapses in coordination and communication as well as failure to appropriately address medication discrepancies. These two cases involve duplicate therapy errors, which have the potential to cause... 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 (14)
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Displaying 1 - 14 of 14 WebM&M Case Studies
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    • Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing
    Janeane Giannini, PharmD, Melinda Wong, PharmD, William Dager, PharmD, Scott MacDonald, MD, and Richard H. White, MD | June 24, 2020
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    • 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.
    “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event
    Sarah Barnhard, MD| January 29, 2020
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    • 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.
    Dying in the Hospital With Advanced Dementia
    Craig A. Umscheid, MD, MSCE; John D. McGreevey, III, MD; and S. Ryan Greysen, MD, MHS, MA| December 1, 2017
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    • Found unconscious at home, an older woman with advanced dementia and end-stage renal disease was resuscitated in the field and taken to the emergency department, where she was registered with a temporary medical record number. Once her actual medical record was identified, her DNR/DNI status was identified. After recognizing this and having discussions with the family, she was transitioned to comfort care and died a few hours later. Two months later, the clinic called the patient's home with an appointment reminder. The primary care physician had not been contacted about the patient's hospitalization and the electronic record system had not listed the patient as deceased.
    Patient Allergies and Electronic Health Records
    Matthew J. Doyle, MBBS| April 1, 2017
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    • Prior to undergoing a CT scan, a patient with no allergies documented in the electronic health record (EHR) described a history of hives after receiving contrast. During a follow-up clinic visit, the patient inquired whether this contrast reaction was listed in the EHR. Investigation revealed that it had been removed from the patient's profile, thus leaving the record with no evidence of allergy to contrast.
    Hyperglycemia and Switching to Subcutaneous Insulin
    Tosha Wetterneck, MD, MS| December 1, 2015
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    • Hospitalized with nonketotic hyperglycemia, a man was placed on IV insulin and his blood sugars improved. That evening, the patient was transferred to the ICU with chest pain and his IV insulin order was changed to sliding scale subcutaneous insulin. However, over the next several hours, the patient again developed hyperglycemia.
    No News May Not Be Good News
    Carlton R. Moore, MD, MS| August 1, 2012
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    • Drawn on a Thursday, basic labs for a 10-year-old girl came back over the weekend showing a high glucose level, but neither the covering physician nor the primary pediatrician saw the results until the patient's mother called on Monday. Upon return to the clinic for follow-up, the child's glucose level was dangerously high and urinalysis showed early signs of diabetic ketoacidosis.
    Pocket Syringe Swap
    John C. Kulli, MD| May 1, 2011
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    • A surgery fellow put two syringes in his pocket: one containing leftover anesthetic and one with agents to reverse it. When it came time to reverse the neuromuscular block, he administered the anesthetic by mistake.
    Mistaken Identity
    Leslie W. Hall, MD| October 1, 2008
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    • Orthopedic surgeons rounding on an elderly Cantonese-speaking woman recommend conservative, nonsurgical treatment for her broken hip, as their examination noted that the patient was able to walk. Given that strict bed rest orders were in place for this patient, a medical intern found the note peculiar. Further investigation revealed that the surgeons had actually walked the patient's roommate, another Cantonese-speaking woman.
    What Was in Those Platelets?
    Roslyn Yomtovian, MD| July 1, 2008
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    • Following spinal surgeries, two different patients developed tachycardia, hypotension, and hypoxia due to sepsis. Given the similarity in clinical course, the hospital investigated and found that both patients had received platelets contaminated with Staphylococcus aureus.
    Crossed Coverage
    Steven R. Kayser, PharmD| February 1, 2007
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    • A woman admitted to the hospital for cardiac transplantation evaluation is mistakenly given warfarin despite an order to hold the dose due to an increase in her INR level.
    The Wet Read
    Ronald L. Arenson, MD| March 1, 2006
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    • A patient with metastatic cancer admitted for pain control develops acute shortness of breath. The overnight resident reads the CT as a large pulmonary embolism, but the next morning, the attending reads it differently.
    Discharge Fumbles
    Alan Forster, MD, MSc| December 1, 2004
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    • A patient arrives at the ED in acute kidney failure; another patient arrives at the ED profoundly hypoglycemic. Both mishaps were determined to stem from medication errors at the time of discharge.
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