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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: August 5, 2022
Samson Lee, PharmD, and Mithu Molla, MD, MBA | August 5, 2022

This WebM&M highlights two cases where home diabetes medications were not reviewed during medication reconciliation and the preventable harm that could have occurred. The commentary discusses the importance of medication reconciliation, how to... 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 (21)

1 - 20 of 21 WebM&M Case Studies
Sarina Fazio, PhD, RN, Emma Blackmon, PhD, RN, Amy Doroy, PhD, RN, Ai Nhat Vu and Paul MacDowell, PharmD. | May 26, 2021

A 64-year-old woman was admitted to the hospital for aortic valve replacement and aortic aneurysm repair. Following surgery, she became hypotensive and was given intravenous fluid boluses and vasopressor support with norepinephrine. On postoperative day 2, a fluid bolus was ordered; however, the fluid bag was attached to the IV line that had the vasopressor at a Y-site and the bolus was initiated. The error was recognized after 15 minutes of infusion, but the patient had ongoing hypotension following the inadvertent bolus. The commentary summarizes the common errors associated with administration of multiple intravenous infusions in intensive care settings and gives recommendations for reducing errors associated with co-administration of infusions.

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Julia Munsch, PharmD and Amy Doroy, PhD, RN | June 24, 2020
A 55-year old woman became unarousable with low oxygen saturation as a result of multiple intravenous benzodiazepine doses given overnight. The benzodiazepine was ordered following a seizure in the intensive care unit (ICU) and was not revised or discontinued upon transfer to the floor; several doses were given for different indications - anxiety and insomnia. This case illustrates the importance of medication reconciliation upon transition of care, careful implementation of medication orders in their entirety, assessment of patient response and consideration of whether an administered medication is working effectively, accurate and complete documentation and communication, and the impact of limited resources during night shift.
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Janeane Giannini, PharmD, Melinda Wong, PharmD, William Dager, PharmD, Scott MacDonald, MD, and Richard H. White, MD | June 24, 2020
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.
Michelle Hamline, MD, PhD, MAS, Georgia McGlynn, RN, MSN-CNL, CPHQ, Andrew Lee, PharmD, and JoAnne Natale, MD, PhD | May 27, 2020
After undergoing a complete atrioventricular canal defect repair, an infant with trisomy 21 was transferred to the pediatric intensive care unit (PICU) and total parenteral nutrition (TPN) was ordered due to low cardiac output. When the TPN order expired, it was not reordered in time for cross-checking by the dietician and pediatric pharmacist and the replacement TPN order was mistakenly entered to include sodium chloride 77 mEq/100 mL, a ten-fold higher concentration than intended. The commentary explores the safety issues with ordering TPN and custom intravenous fluids in a pediatric population, and the critical role of clinical decision support systems and the healthcare team (physicians, pharmacists, nurses and dieticians) in preventing medication-related errors.
Two patients admitted for deceased donor renal transplant surgery experienced similar near miss errors involving 1000 ml normal saline bags with 160mg gentamicin intended as bladder irrigation but mistakenly found spiked or next to the patient’s intravenous (IV) line. Confusion about using this nephrotoxic drug intravenously could result in significant harm to patients undergoing renal transplant surgery.
Nasim Wiegley, M.D. and José A. Morfín, M.D. | January 29, 2020
A 54-year-old man was found unconscious at home with multiple empty bottles of alcoholic beverages nearby and was brought to the emergency department by his family members. He was confused and severely hyponatremic, so he was admitted to the intensive care unit (ICU). His hospital stay was complicated by an error in the administration of hypertonic saline.
Elise Orvedal Leiten, MD, and Rune Nielsen, MD, PhD| January 1, 2019
Hospitalized in the ICU with hypoxic respiratory failure due to community-acquired pneumonia, an elderly man had increased pulmonary secretions on hospital day 2 for which the critical care provider decided to perform bedside bronchoscopy. Following the procedure, the patient was difficult to arouse, nearly apneic, and required intubation. The care team paused and discovered that after the patient had received 2 mg of intravenous midalozam, his IV line had been flushed with an additional 10 mg of the benzodiazepine, rather than the intended normal saline. This high dose of midazolam led to the respiratory failure requiring intubation. On top of that, instead of normal saline, lidocaine had been used for the lung lavage.
Rodney W. Hicks, PhD, RN, FNP| February 1, 2013
After delivering a healthy infant via Caesarean section, a young woman was to receive morphine via PCA pump. A mix-up in programming the concentration of medication delivered by the pump led to a fatal outcome.
Elizabeth Manias, PhD, RN, MPharm| October 1, 2012
After having a seizure in the emergency department, a woman was to receive intravenous administration of an antiseizure medication. The nurse misread the medication order, gathered 32 vials of the medication, and administered a 10-fold overdose to the patient, who died several minutes later.
Debora Simmons, PhD, RN| September 1, 2011
Following surgery, a cancer patient was receiving total parenteral nutrition and lipids through a central venous catheter and pain control through an epidural catheter. A nurse mistakenly connected a new bottle of lipids to the epidural tubing rather than the central line, and the error was not noticed for several hours.
Robert J. Weber, PharmD, MS| February 1, 2010
An elderly woman presented to the emergency department following a hip fracture. Although the patient's medication bottles were used to generate a medication list, one of the dosages was transcribed incorrectly. Because the patient then received four times her regular dose, her surgery was delayed due to cardiac side effects.
Dorrie K. Fontaine, RN, PhD| October 1, 2009
A toddler admitted for severe dehydration requires a femoral IV. The anesthesiologist ignores a nurse's reminder that hospital policy requires monitoring if a child is to receive sedation in the unit. When the nurse attempts to stop the procedure, the anesthesiologist throws the needle to the floor.
Hedy Cohen, RN, BSN, MS| March 21, 2009
New medication administration policies at one hospital cause a patient to receive two doses of her daily medication within a few hours, when only one dose was intended.
Jill R. Scott-Cawiezell, RN, PhD| July 1, 2008
An elderly man receiving feedings through a percutaneous enterostomy tube was prescribed intravenous total parenteral nutrition (TPN). A licensed practical nurse (LPN) mistakenly connected the TPN to the patient's enterostomy tube. His daughter (a retired nurse) asked her about it, and the RN on duty confirmed the error. The LPN disconnected the mistakenly placed (and now contaminated) line, but then prepared to attach it to the intravenous catheter. Luckily, both the patient's daughter and the RN were present and stopped her.
Elizabeth A. Henneman, RN, PhD| May 1, 2007
A young woman with Takayasu's arteritis, a vascular condition that can cause BP differences in each arm, was mistakenly placed on a powerful intravenous vasopressor because of a spurious low BP reading. The medication could have led to serious complications.
Patrice L. Spath, BA, RHIT| March 1, 2007
An infant receives an overdose of the wrong antibiotic (cephazolin instead of ceftriaxone). The nurse spoke with the ED physician on duty but was informed that the medications were essentially equivalent and did not report the error.
Richard Hellman, MD| March 1, 2007
For a woman with insulin-dependent diabetes mellitus, the admitting medical team ordered sliding scale insulin. Her blood glucose levels became very difficult to control, and she developed diabetic ketoacidosis. In the morning, the physician instituted a more appropriate insulin regimen.
Mary A. Blegen, PhD, RN; Ginette A. Pepper, PhD, RN| May 1, 2006
A nursing student administers the wrong 'cup' of medications to an elderly man. A different student discovered the error when she reviewed the medicines in her patient's cup and noticed they were the wrong ones.
Tess Pape, PhD, RN, CNOR| February 1, 2006
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.