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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: April 26, 2023
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 (11)
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Displaying 1 - 11 of 11 WebM&M Case Studies
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    • 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.
    July Syndrome
    John Q. Young, MD, MPP| June 1, 2016
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    • Multiple transitions and assumptions made during the first week in July, when the graduating fellow had left and a new fellow and intern had begun on the surgery service, led to a patient mistakenly not receiving medication to prevent venous thromboembolism until several days after his surgery.
    Hyperglycemia and Switching to Subcutaneous Insulin
    Tosha Wetterneck, MD, MS| December 1, 2015
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    • Hospitalized with nonketotic hyperglycemia, a man was placed on IV insulin and his blood sugars improved. That evening, the patient was transferred to the ICU with chest pain and his IV insulin order was changed to sliding scale subcutaneous insulin. However, over the next several hours, the patient again developed hyperglycemia.
    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.
    Not-So-Therapeutic Tap
    Jeffrey H. Barsuk, MD, MS| July 1, 2012
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    • Following gallbladder removal, a patient presented with abdominal pain and fluid in her abdomen. The admitting team, comprised of a second-year resident and intern, decided to perform a paracentesis (fluid removal) without supervision. The patient had a complication necessitating emergency surgery and an ICU stay.
    E-prescribing: E for error?
    Elisa W. Ashton, PharmD| February 1, 2012
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    • After entering an electronic prescription for the wrong patient, the clinic nurse deleted it, assuming that would cancel the order at the pharmacy. However, the prescription went through to the pharmacy, and the patient received it.
    The Wet Read
    Ronald L. Arenson, MD| March 1, 2006
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    • A patient with metastatic cancer admitted for pain control develops acute shortness of breath. The overnight resident reads the CT as a large pulmonary embolism, but the next morning, the attending reads it differently.
    Liposuction Gone Awry
    James A. Yates, MD| March 1, 2006
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    • A man undergoes plastic surgery at an outpatient center and winds up with a complication requiring prolonged stay in the ICU.
    The Other Side
    Charles Vincent, PhD| October 1, 2003
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    • Trusting his memory more than the chart, a surgeon directs a resident to remove the wrong side on a patient with unilateral vulvar cancer.
    Check the Wristband
    Marilynn M. Rosenthal, PhD| July 1, 2003
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    • An anxious patient awaiting ambulatory surgery is mistakenly put on the wrong operating table.
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