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: 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 (8)

1 - 8 of 8 WebM&M Case Studies
Nandakishor Kapa, M.D., and José A. Morfín, M.D.| February 23, 2022

A 69-year-old man with End-Stage Kidney Disease (ESKD) secondary to diabetes mellitus and hypertension, who had been on dialysis since 2014, underwent deceased donor kidney transplant. The case demonstrates the complex nature of management of allograft dysfunction due to vascular complications in a patient with deceased donor kidney transplant in the early post-transplant period. The commentary discusses how standardized follow-up imaging protocols can support early recognition and evaluation of allograft dysfunction due to vascular complications in kidney transplant recipients, as well the importance of team communication for patients requiring multiple interventions to reduce lag time in addressing further complications.

Jeffrey Jim, MD, MPHS| August 1, 2018
An older man with multiple medical conditions and an extensive smoking history was admitted to the hospital with worsening shortness of breath. He underwent transthoracic echocardiogram, which demonstrated severe aortic stenosis. The cardiology team recommended cardiac catheterization, but the interventional cardiologist could not advance the catheter and an aortogram revealed an abdominal aortic aneurysm (AAA) measuring 9 cm in diameter. Despite annual visits to his primary care physician, he had never undergone screening ultrasound to assess for presence of an AAA. The patient was sent emergently for surgical repair but had a complicated surgical course.
Elliott K. Main, MD| November 1, 2016
After an emergency cesarean delivery, a woman had progressive tachycardia and persistent hypertension. A CT scan showed no evidence of pulmonary embolism, but repeat blood tests showed a dangerously low hemoglobin level and markedly elevated liver enzyme levels. She was taken back to the operating room and found to have postpartum hemorrhage.
Caprice C. Greenberg, MD, MPH| October 1, 2010
Following an appendectomy, an elderly man continued to have right lower quadrant pain. Reviewing the specimen removed during the surgery, the pathologist found no appendiceal tissue. The patient was emergently taken back to the OR, and the appendix was located and removed.
Gerald W. Smetana, MD| June 1, 2007
Based on preoperative discussions, a patient undergoing knee replacement expected to receive spinal anesthesia; however, general anesthesia was administered, and the records did not note or explain this change. The patient suffered an unusual complication.
Marc J. Shapiro, MD| February 1, 2004
Trusting an incorrectly labeled chest x-ray over physical exam findings, a resident places a chest tube for pneumothorax in the wrong side.
J. Forrest Calland, MD| January 1, 2004
During a hernia repair, surgeons decide to remove a patient's hydrocele, spermatic cord, and left testicle—without realizing that his right testicle had been removed previously.