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.

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This Month's WebM&Ms

Update Date: March 15, 2023

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Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation

Jonathan Trask, RN, Kathleen M. Carlsen, PA, Brooks T. Kuhn, MD | March 15, 2023

A 72-year-old man was diagnosed with COVID-19 pneumonia and ileus, and admitted to a specialized COVID care unit. A nasogastric tube (NGT) was placed, supplemental oxygen was provided, and oral feedings were... Read More

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Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists

Lucy Shi, MD and Erik Noren MD, MS | March 15, 2023

A 71-year-old man presented to his physician with rectal bleeding and pain, which was attributed to radiation proctitis following therapy for adenocarcinoma of the prostate. He subsequently developed a potentially life... Read More

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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

Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm.

Christian Bohringer, MD | March 15, 2023

A 48-year-old woman was placed under general anesthesia with a laryngeal mask. The anesthesiologist was distracted briefly to sign for opioid drugs in a register, and during this time,... 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

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All WebM&M: Case Studies (28)

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Displaying 1 - 20 of 28 WebM&M Case Studies

Management of Cardiac Arrest in Unconventional Locations.

Garima Agrawal, MD, MPH, and Mithu Molla, MD, MBA | May 16, 2022

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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 prepared to deliver advanced cardiac life support (ACLS), such as the use of mock codes and standardized ACLS algorithms.

Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities

Jeremiah Duby, PharmD, Kendra Schomer, PharmD, Victoria Oyewole, PharmD, Delia Christian, RN, BSN, CNRN, and Sierra Young, PharmD| May 26, 2021

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A 65-year-old man with a history of type 2 diabetes mellitus, hypertension, and coronary artery disease was transferred from a Level III trauma center to a Level I trauma center with lower extremity paralysis after a ground level fall complicated by a 9-cm abdominal aortic aneurysm and cervical spinal cord injury. Post transfer, the patient was noted to have rapidly progressive ascending paralysis. Magnetic resonance imaging (MRI) revealed severe spinal stenosis involving C3-4 and post-traumatic cord edema/contusion involving C6-7. A continuous intravenous (IV) infusion of norepinephrine was initiated to maintain adequate spinal cord perfusion, with a target mean arterial pressure goal of greater than 85 mmHg. Unfortunately, norepinephrine was incorrectly programmed into the infusion pump for a weight-based dose of 0.5 mcg/kg/min rather than the ordered dose of 0.5 mcg/min, resulting in a dose that was 70 times greater than intended. The patient experienced bradycardia and cardiac arrest and subsequently died.

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.

Complications of ECMO During Transport

Mikael Broman, MD, PhD| April 29, 2020

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A 54-year old women with chronic obstructive pulmonary disease was admitted for chronic respiratory failure. Due to severe hypoxemia, she was intubated, mechanically ventilated and required extracorporeal membrane oxygenation (ECMO). During the hospitalization, she developed clotting problems, which necessitated transfer to the operating room to change one of the ECMO components. On the way back to the intensive care unit, a piece of equipment became snagged on the elevator door and the system alarmed. The perfusionist arrived 30-minutes later and realized that the ECMO machine was introducing room air to the patient’s circulation, leading to air embolism. The patient became severely hypotensive and bradycardic, and despite aggressive attempts at resuscitation, she died.

The Need to Eat

Adrianne M Widaman, PhD, RD | December 18, 2019

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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.

If You Say So: Taking a Syringe at Face Value in the Operating Room

Audrey Lyndon, PhD, RN, and Stephanie Lim, MD| June 1, 2019

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During surgery for a forearm fracture, a woman experienced a drop in heart rate to below 50 beats per minute. As the consultant anesthesiologist had stepped out to care for another patient, the resident asked the technician to draw up atropine for the patient. When the technician returned with an unlabeled syringe without the medication vial, the resident was reluctant to administer the medication, but did so without a double check after the technician insisted it was atropine. Over the next few minutes, the patient's blood pressure spiked to 250/135 mm Hg.

Duplicate Insulin Order

Nicole M. Acquisto, PharmD, and Daniel J. Cobaugh, PharmD| March 1, 2019

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Seen in the emergency department, a man with insulin-dependent diabetes mellitus had not taken insulin for 3 days. His blood glucose levels were in the 800s with an anion-gap acidosis and positive beta hydroxybutyrate. While awaiting an ICU bed for treatment of diabetic ketoacidosis, the patient received fluids, an insulin drip was started, and blood glucose levels were monitored hourly. When lab results showed he was improving, the team decided to convert his insulin drip to subcutaneous long-acting insulin. However, both the intern and the resident ordered 50 units of insulin, and the patient received both doses—causing his blood glucose level to dip into the 30s.

One Bronchoscopy, Two Errors

Elise Orvedal Leiten, MD, and Rune Nielsen, MD, PhD| January 1, 2019

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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.

Are We Pushing Graduate Nurses Too Fast?

Nancy Spector, PhD, RN | March 1, 2011

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While caring for a complex patient in the surgical intensive care unit, a nurse incorrectly set up the continuous renal replacement therapy (CRRT) machine, raising questions about how new nurses should be trained in high-risk procedures.

Medication Reconciliation Pitfalls

Robert J. Weber, PharmD, MS| February 1, 2010

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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.

Difficult Encounters: A CMO and CNO Respond

Ernest J. Ring, MD; Jane E. Hirsch, RN, MS| October 1, 2009

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Cardiology consultation on an elderly man admitted to the orthopedic service following a hip fracture reveals aortic stenosis. The cardiologist recommends against surgery, due to the risk of anesthesia. When the nurse reads these recommendations to the orthopedic resident, he calls her "stupid" and contacts the OR to schedule the surgery anyway. The Chief Medical Officer is called to intervene.

Danger in Disruption

Dorrie K. Fontaine, RN, PhD| October 1, 2009

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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.

Double Dosing, by the Rules

Hedy Cohen, RN, BSN, MS| March 21, 2009

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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.

Cups of Error

Mary A. Blegen, PhD, RN; Ginette A. Pepper, PhD, RN| May 1, 2006

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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.

Thin Air

David M. Gaba, MD | October 1, 2004

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A dyspneic patient fails to improve after being placed on high-flow oxygen. The respiratory therapist soon discovers why: the patient is mistakenly receiving compressed room air.

Caution, Interrupted

Robert L. Wears, MD, MS| September 1, 2004

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A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and winds up hanging the bag anyway.

Glucose Roller Coaster

Bradley A. Sharpe, MD| July 1, 2004

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A woman hospitalized for CHF (with no history of diabetes) is given several rounds of insulin and D50, after repeated blood tests show her glucose to be dangerously high, then dangerously low. Turns out, the blood samples were drawn incorrectly and the signouts were incomplete.

The Result Stopped Here

Michael Astion, MD, PhD| June 1, 2004

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Just before leaving for the weekend, a physician orders a test for a communicable infection. Although the result arrives and isolation signs are placed on the patient's door, none of the covering physicians are notified, and the float nurses mistakenly assume the patient is already receiving treatment.

Environmental Safety in the OR

Darren R. Linkin, MD; Ebbing Lautenbach, MD, MPH, MSCE| February 1, 2004

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Infection Control notices an uptick in post-operative wound infections for patients from one OR team. Environmental rounds reveal "sloppy" practices.

Triage Time Bomb

Donna L. Washington, MD, MPH| January 1, 2004

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A triage nurse instructed by a physician to immediately bring a febrile child, who was possibly dehydrated, to the treatment area is stopped by the charge nurse, citing overcrowding. The parents seek treatment elsewhere; upon arrival, the child is in full arrest.

WebM&M: Case Studies

This Month's WebM&Ms

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