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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: March 15, 2023
New
Medication Handling and Compounding Errors in the Operating Room.
Joy Chaudhry, PharmD, BCPS, BCCCP, Julie Chou BSN, RN, CNOR, Courtney Manning, PharmD, MBA, Minji Kim, RN, BSN, CNOR, and David Dakwa, PharmD, MBA, BCPS, BCSCP | March 15, 2023

This case focuses on immediate-use medication compounding in the operating room and how the process creates situations in which medication errors can occur. The commentary discusses strategies for safe perioperative compounding and the... Read More

New
Duplicate Therapies in Retail Pharmacy
Nisha Punatar, MD, Samson Lee, PharmD, BCACP, and Mithu Molla, MD, MBA | March 15, 2023

The cases described in this WebM&M reflect fragmented care with lapses in coordination and communication as well as failure to appropriately address medication discrepancies. These two cases involve duplicate therapy errors, which have the potential to cause... 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 (13)
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Displaying 1 - 13 of 13 WebM&M Case Studies
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    • Misidentifying the Unidentified – John Doe and the EHR
    Christopher F. Janowak, MD, FACS, and Lauren M. Janowak, RN, BSN, CCRN| October 30, 2019
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    • 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.
    New Patient Mistakenly Checked in as Another
    Robert A. Green, MD, MPH, and Jason Adelman, MD, MS| January 1, 2016
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    • Presenting to his new primary physician's office for his first visit, a man was checked in under the record of an existing patient with the exact same name and age. The mistake wasn't noticed until the established patient received the new patient's test results by email.
    Privacy or Safety?
    John D. Halamka, MD, MS, and Deven McGraw, JD, MPH, LLM| August 21, 2015
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    • 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.
    The ECG Is Not Normal
    Abigail Zuger, MD| June 1, 2011
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    • An adolescent girl passed out after a soccer game, and her father, a physician, took her to the pediatrician for tests. The physician father obtained a copy of his daughter’s ECG, panicked because it was not normal, and began guiding his daughter’s medical care.
    Mother's Milk, but Whose Mother?
    Dorothy Dougherty, RN| November 1, 2010
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    • A hospitalized 2-month-old infant is fed breast milk from another infant's mother after the wrong bottle is pulled from the ward's refrigerator.
    EMR Entry Error: Not So Benign
    Ross Koppel, PhD| April 1, 2009
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    • A patient hospitalized with Pneumocystis jiroveci pneumonia and advanced AIDS is given another patient's malignant biopsy results, leading his primary physician to mistakenly recommend hospice care.
    Right? Left? Neither!
    Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD, MPP, MPH| May 1, 2006
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    • A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.
    Overriding Considerations
    Neil A. Holtzman, MD, MPH| December 1, 2004
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    • A pregnant woman is offered genetic testing for herself and her husband. Although he declines, the next time he undergoes routine testing, the phlebotomist overrides the consent in the computerized record and runs the test anyway.
    Listen to the Family
    Darrell Campbell, Jr., MD| June 1, 2004
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    • Despite persuasion from a surgical resident that her mother's life was in danger, a patient's daughter refuses consent for surgery on her mother. This was wise, since the procedure was intended for a different patient with the same unusual surname.
    Transfusion "Slip"
    Harold S. Kaplan, MD| February 1, 2004
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    • Blood typing tubes for a married couple brought to an ED after a trauma are labeled with the opposite stickers. By coincidence, the wife's blood type was already on file. An alert blood-bank technologist catches the mistake.
    To Resuscitate or Not?
    Albert W. Wu, MD, MPH; Peter J. Pronovost, MD, PhD| January 1, 2004
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    • A patient receiving end-of-life care, whose code status was DNR, encounters a potentially life-threatening medication error.
    Check the Wristband
    Marilynn M. Rosenthal, PhD| July 1, 2003
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    • An anxious patient awaiting ambulatory surgery is mistakenly put on the wrong operating table.
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