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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: 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 (2)

Published Date
PSNet Publication Date
1 - 2 of 2 WebM&M Case Studies
Katrina Pasao, MD and Pouria Kashkouli, MD, MS | March 31, 2022

This Spotlight Case describes an older man incidentally diagnosed with prostate cancer, with metastases to the bone. He was seen in clinic one month after that discharge, without family present, and scheduled for outpatient biopsy. He showed up to the biopsy without adequate preparation and so it was rescheduled. He did not show up to the following four oncology appointments. Over the course of the following year, the patient’s son and daughter were contacted at various points to re-establish care, but he continued to miss scheduled appointments and treatments. During a hospital admission, a palliative care team determined that the patient did not have capacity to make complex medical decisions. He was discharged to a skilled nursing facility, and then to a board and care when he failed to improve. He missed two more oncology appointments before being admitted with cancer-related pain. Based on the patient’s poor functional status, he was not considered a candidate for additional therapy. After a discussion of goals of care with the patient and daughter, he was enrolled in hospice. The commentary outlines key elements for assessing patient capacity, the importance of understanding the patient’s psychosocial history, and strategies to strengthen psychosocial training for medical and nursing trainees.

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A 52-year-old man complaining of intermittent left shoulder pain for several years was diagnosed with a rotator cuff injury and underwent left shoulder surgery. The patient received a routine follow-up X-ray four months later. The radiologist interpreted the film as normal but noted a soft tissue density in the chest and advised a follow-up chest X-ray for further evaluation. Although the radiologist’s report was sent to the orthopedic surgeon’s office, the surgeon independently read and interpreted the same images and did not note the soft tissue density or order any follow-up studies. Several months later, the patient’s primary care provider ordered further evaluation and lung cancer was diagnosed. The commentary discusses how miscommunication contributes to delays in diagnosis and treatment and strategies to facilitate effective communication between radiologists and referring clinicians.  

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