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

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... Read More

Alexandria DePew, MSN, RN, James Rice, & Julie Chou, BSN | May 16, 2022

This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an... 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 (4)

1 - 4 of 4 WebM&M Case Studies
Christopher F. Janowak, MD, FACS, and Lauren M. Janowak, RN, BSN, CCRN| October 30, 2019
Two patients arrived at the Emergency Department (ED) at the same time with major trauma. Both patients were unidentified and were given "Doe" names. Patient 1 was quickly sent to the operating room (OR) but the ED nurse incorrectly gave him Patient 2's "Doe" name. The OR nurse only realized there was a problem when blood arrived with Patient 1's correct "Doe" name, requiring multiple phone calls with the ED, laboratory, and surgeon to correctly identify the patient.
John Day and John T. Paige, MD| May 1, 2019
An elderly man with a complicated medical history slipped on a rug at home, fell, and injured his hip. Emergency department evaluation and imaging revealed no head injury and a left intertrochanteric hip fracture. Although he was admitted to the orthopedic surgery service with surgery to fix the fracture initially scheduled for the next day, the operation was delayed by 3 days due to several emergent trauma cases and lack of surgeon availability. He ultimately underwent surgery and was discharged a few days later but was readmitted several weeks later with chest pain and shortness of breath. He was found to have a pulmonary embolism; anticoagulation was initiated. The patient's rehabilitation was delayed, his recovery was prolonged, and he never returned to his baseline functional status.
Yael K. Heher, MD, MPH| November 1, 2017
A resident entered orders into the EHR for a biopsy specimen of a patient's rash to be sent to pathology for evaluation. The biopsy specimen was delivered to the laboratory without a copy of the orders. Because pathology and the medicine service did not share the same EHR, the laboratory could neither view the orders nor direct the biopsy to the appropriate area for analysis without a printed copy. The next day, the resident attempted to look up the results but found none.
John D. Halamka, MD, MS, and Deven McGraw, JD, MPH, LLM| August 21, 2015
A hospitalized patient with advanced dementia was to undergo a brain MRI as part of a diagnostic workup for altered mental status. Hospital policy dictated that signout documentation include only patients' initials rather than more identifiable information such as full name or birth date. In this case, the patient requiring the brain MRI had the same initials as another patient on the same unit with severe cognitive impairment from a traumatic brain injury. The cross-covering resident mixed up the two patients and placed the MRI order in the wrong chart. Because the order for a "brain MRI to evaluate worsening cognitive function" could apply to either patient, neither the bedside nurse nor radiologist noticed the error.