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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 (4)

Displaying 1 - 4 of 4 WebM&M Case Studies

A 65-year-old female with a documented allergy to latex underwent surgery for right-sided Zenker’s diverticulum. Near the conclusion of surgery, a latex Penrose drain was placed in the neck surgical incision. The patient developed generalized urticaria, bronchospasm requiring high airway pressures to achieve adequate ventilation, and hypotension within 5 minutes of placement of the drain. The drain was removed and replaced with a silicone drain. Epinephrine and vasopressors were administered post-operatively and the patient’s symptoms resolved. The commentary discusses risk factors and consequences of latex allergy in hospital and operating room settings, common latex products that trigger allergic reactions  and hospital safety practices that can limit the risk of latex exposure.

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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.
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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