Skip to main content

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... 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)

1 - 4 of 4 WebM&M Case Studies
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.
Christopher F. Janowak, MD, FACS, and Lauren M. Janowak, RN, BSN, CCRN| October 30, 2019
Two patients arrived at the Emergency Department (ED) at the same time with major trauma. Both patients were unidentified and were given "Doe" names. Patient 1 was quickly sent to the operating room (OR) but the ED nurse incorrectly gave him Patient 2's "Doe" name. The OR nurse only realized there was a problem when blood arrived with Patient 1's correct "Doe" name, requiring multiple phone calls with the ED, laboratory, and surgeon to correctly identify the patient.
Neal L. Benowitz, MD| April 1, 2019
A woman who required oxygen at home via nasal cannula and used a continuous positive airway pressure (CPAP) machine at night was admitted for an exacerbation of chronic obstructive pulmonary disease without any signs of infection. During her hospital stay, she continued to require 5 liters of oxygen by nasal cannula. Although the patient had received smoking cessation education and no longer smoked regular cigarettes, she did continue to vape with an electronic cigarette (e-cigarette). Having not been told to avoid vaping in the hospital, the patient took a puff on her e-cigarette while she was receiving oxygen through her nasal cannula and sparked an explosion. She ripped off the nasal cannula, which had melted, and sustained burns to her face and hand, resulting in a prolonged hospitalization for burn care and extensive pain management.
An ICU patient with head and spine trauma was sent for an MRI. Due his critical condition, hospital policy required a physician and nurse to accompany the patient to the MRI scanner. The ICU attending assigned a new intern, who felt unprepared to handle any crises that might arise, to transport the patient along with the nurse. While in a holding area awaiting the MRI, the patient's heart rate fell below 20 beats per minute, and the experienced ICU nurse administered atropine to recover his heart rate and blood pressure. The intern worried he had placed the patient's life at risk because of his inexperience, but he also felt uncomfortable speaking up.