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: February 1, 2023
Craig Keenan, MD, Scott MacDonald, MD, Ashley Takeshita, and Dale Sapell, PharmD | February 1, 2023

A 38-year-old man with end-stage renal disease (ESRD) on chronic hemodialysis was admitted for nonhealing, infected lower leg wounds and underwent a below-knee amputation. He suffered from postoperative pain at the operative stump and was treated for... Read More

Take the Quiz
Elizabeth Partridge, MD, MPH, Daniel Dodson, MD, MS, Mary Reilly, MHA, BSN, RN, CIC and Stuart H. Cohen, MD | February 1, 2023

A 5-day old male infant was admitted to the pediatric intensive care unit (PICU) and underwent surgery to correct a congenital heart defect. The patient’s postoperative course was complicated Staphylococcus aureus bacteremia and other problems,... Read More

Dahlia Zuidema, PharmD, Berit Bagley, MSN, and Charity L Tan MSN | February 1, 2023

This WebM&M highlights two cases of hospital-acquired diabetic ketoacidosis (DKA) in patients with type 1 diabetes. The commentary discusses the role of the inpatient glycemic team to assist with diabetes management, the importance of medication... Read More

Nicole A. Weiss, MD | February 1, 2023

A 27-year-old pregnant woman was diagnosed with severe pulmonary arterial hypertension at 29 weeks estimated gestational age (EGA) and admitted for elective cesarean delivery with lumbar epidural anesthesia at 36 weeks EGA. After epidural catheter... 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 (9)

Displaying 1 - 9 of 9 WebM&M Case Studies
David Barnes, MD and Joseph Yoon, MD | April 27, 2022

An 18-month-old girl presented to the Emergency Department (ED) after being attacked by a dog and sustaining multiple penetrating injuries to her head and neck. After multiple unsuccessful attempts to establish intravenous access, an intraosseous (IO) line was placed in the patient’s proximal left tibia to facilitate administration of fluids, blood products, vasopressors, and antibiotics.  In the operating room, peripheral intravenous (IV) access was eventually obtained after which intraoperative use of the IO line was restricted to a low-rate fluid infusion.  An hour into the operation, the anesthesiologist found her left calf to be warm and tense, presumably due to fluid extravasation from the IO line.  The IO line was removed, and the Orthopedic Surgery service was consulted intraoperatively due to concern for acute compartment syndrome.  Signs of compartment syndrome eventually resolved without any surgical intervention.  The commentary summarizes complications associated with IO lines, the importance of anticipating procedural complications, and methods to identify the signs and symptoms of acute compartment syndrome.

Take the Quiz
Marissa G. Vadi, MD, MPH, and Mathew R. Malkin, MD | October 27, 2021

A 6-week-old infant underwent a craniotomy and excision of abnormal brain tissue for treatment of hemimegalencephaly and epilepsy. A right femoral central venous catheter and an arterial catheter were inserted, as well as 22-gauge intravenous catheter inserted into the external jugular vein, which was covered with surgical drapes.  During the surgical procedure, the neurosurgeon adjusted the patient’s head, displacing the external jugular intravenous catheter into the subcutaneous tissue.  The catheter’s dislodgment went unnoticed due to its position underneath the surgical drapes. The commentary discusses the importance intraoperative monitoring of intravenous catheters and the use of surgical safety checklists to improve communication and prevent surgical complications.

Christopher R. Lee, MD| October 1, 2009
Following surgery for peripheral vascular disease, a patient otherwise ready for discharge complains of liquid shooting from his nose. The surgeons make the patient NPO and order a consultation from an otolaryngologist, who discovers the nasopharyngeal airway still lodged in the patient's nasal cavity.
Jose L. Baez-Escudero, MD; Glenn N. Levine, MD| September 1, 2007
A man underwent coronary angiography; one stent was placed and bypass surgery was scheduled for 4 days later. He developed bleeding at the catheter site and returned to the hospital. A CT scan revealed a large retroperitoneal hematoma, which was repaired surgically. While in the hospital awaiting the delayed bypass surgery, the patient had a cardiac arrest and died.
Angela C. Joseph, RN, MSN, CURN| November 1, 2006
Following elective surgery, a man with benign prostatic hypertrophy began having trouble with urination. Delay in addressing this issue caused discomfort and the need for catheterization and antibiotics.
Jonathan S. Jahr, MD; Puya Hosseini| November 1, 2006
An elderly woman underwent knee replacement, during which her airway was maintained with a laryngeal mask airway. However, she developed a fever and fullness in her neck, which a CT scan revealed to be retropharyngeal and mediastinal abscesses.
Kay Ball, RN, MSA | October 1, 2004
While repositioning the trocar, a surgeon places the laparoscope on a tray sitting on the patient. When she picks it back up, she notices that the drape has melted and the patient has a second-degree burn.