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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 (8)
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Displaying 1 - 8 of 8 WebM&M Case Studies
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    • Patient Identification Errors: A Systems Challenge
    Lamia S. Choudhury, MS1 and Catherine T Vu, MD| January 29, 2020
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    • 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.
    The Hazards of Distraction: Ticking All the EHR Boxes
    Anthony C. Easty, PhD| February 1, 2017
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    • A few weeks after falling and hitting her head, a woman with metastatic cancer was admitted to the hospital for observation after a brain scan showed a subdural hematoma with a midline shift. Repeat imaging showed an enlarging hematoma, which required surgical evacuation. The admitting provider had mistakenly prescribed blood thinner for venous thromboembolism prophylaxis (contraindicated in the setting of subdural hematoma) by clicking the box in the electronic health record admission order set.
    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.
    Triple Handoff
    Arpana R. Vidyarthi, MD| September 1, 2006
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    • An elderly man was admitted to the hospital for pacemaker placement. Although the postoperative chest film was normal, the patient later developed shortness of breath. Over the course of several nursing and physician shift changes and signouts, results of a follow-up stat x-ray are not properly obtained, delaying discovery of the patient's pneumothorax.
    Deciphering the Code
    Mary K. Goldstein, MD, MS | February 1, 2006
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    • Failure to enter documentation of a DNR order causes a severely ill elderly man to be resuscitated against his wishes. Shortly thereafter, the patient's wife confirms his wishes, and within minutes, the patient dies.
    Workaround Error
    Tess Pape, PhD, RN, CNOR| February 1, 2006
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    • Bypassing the safeguards of an automated dispensing machine in a skilled nursing facility, a nurse administers medications from a portable medication cart. A non-diabetic patient receives insulin by mistake, which requires his admission to intensive care and delays his chemotherapy for cancer.
    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.
    Transfusion "Slip"
    Harold S. Kaplan, MD| February 1, 2004
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    • Blood typing tubes for a married couple brought to an ED after a trauma are labeled with the opposite stickers. By coincidence, the wife's blood type was already on file. An alert blood-bank technologist catches the mistake.
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