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: November 16, 2022
Nasim Hedayati, MD, and Richard White, MD | November 16, 2022

A 61-year-old women with a mechanical aortic valve on chronic warfarin therapy was referred to the emergency department (ED) for urgent computed tomography (CT) imaging of the right leg to rule out an arterial clot. CT imaging revealed two... Read More

Leilani Schweitzer | November 16, 2022

A 58-year-old man underwent a complex surgery to replace his aortic valve. The surgery required prolonged cardiopulmonary bypass time and cross-clamp time and there was a short delay in redosing the cardioplegic solution and the patient developed ... 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 (5)

Displaying 1 - 5 of 5 WebM&M Case Studies

A 49-year-old woman presented to an Emergency Department (ED) with abdominal pain nine hours after discharge following outpatient laparoscopic left oophorectomy. The left oophorectomy procedure involved an umbilical port placed using an Optiport visual trocar, a suprapubic port, and two additional ports laterally. The operative note mentioned no visible injury upon entry into the abdominal cavity, but there were extensive adhesions in the pelvis. Nine hours after discharge, the patient presented to another hospital due to increasing pain, nausea, and fever. The patient underwent a laparotomy and the surgical team found fecal contamination upon entry into the peritoneal cavity; the surgeons concluded that the most plausible explanation was a trocar injury. The commentary discusses the risk of vascular and bowel injury during peritoneal access for laparoscopy and the importance of patient history and abdominal anatomy when considering approaches to abdominal entry.

Take the Quiz

A 65-year-old female with a documented allergy to latex underwent surgery for right-sided Zenker’s diverticulum. Near the conclusion of surgery, a latex Penrose drain was placed in the neck surgical incision. The patient developed generalized urticaria, bronchospasm requiring high airway pressures to achieve adequate ventilation, and hypotension within 5 minutes of placement of the drain. The drain was removed and replaced with a silicone drain. Epinephrine and vasopressors were administered post-operatively and the patient’s symptoms resolved. The commentary discusses risk factors and consequences of latex allergy in hospital and operating room settings, common latex products that trigger allergic reactions  and hospital safety practices that can limit the risk of latex exposure.

Take the Quiz

A 34-year-old morbidly obese man was placed under general anesthesia to treat a pilonidal abscess. Upon initial evaluation by an anesthesiologist, he was found to have a short thick neck, suggesting that endotracheal intubation might be difficult. A fellow anesthetist suggested use of video-laryngoscopy equipment, but the attending anesthesiologist rejected the suggestion. A first-year resident attempted to intubate the patient but failed. The attending anesthesiologist took over, but before intubation could be performed, the patient desaturated to 40-50%. A second attempt by the attending anesthesiologist at intubation with a glide scope also failed. The patient’s arterial saturation increased after administration of 100% oxygen by mask and he suffered no apparent neurological consequences. The commentary discusses best practices for managing high risk patients and appropriate use of advanced airway management devices.

Marilynn M. Rosenthal, PhD| July 1, 2003
An anxious patient awaiting ambulatory surgery is mistakenly put on the wrong operating table.