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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: November 30, 2023
New
Medication Mix-Up Leads to Patient Death.
Luciano Sanchez, PharmD and Patrick Romano, MD, MPH | November 30, 2023

An 81-year-old man was admitted to the intensive care unit (ICU) with a gastrointestinal bleed and referred for a diagnostic colonoscopy. The nurse preparing... 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 (8)
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    • Discontinued Medications: Are They Really Discontinued?
    Celina Garza Mankey, MD, and Prathibha Varkey, MD, MPH, MBA| May 1, 2014
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    • An elderly man on warfarin and aspirin for chronic atrial fibrillation and previous cerebrovascular accident presented to the emergency department with a severe headache. Found to have bilateral subdural hematomas and a supratherapeutic INR (4.9), he was admitted to the ICU. Even though the patient was discharged with his warfarin discontinued permanently, the outpatient pharmacy kept it on the active medication list and refilled his mail order prescription automatically, leading again to an elevated INR.
    Watch the Warfarin!
    Margaret Fang, MD, MPH; Raman Khanna, MD, MAS| July 1, 2011
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    • Following hospitalization for community-acquired pneumonia, an elderly man with a history of dementia, falls, and atrial fibrillation is discharged on antibiotics but no changes to his anticoagulation medication. One week later, the patient’s INR was dangerously high.
    Reconciling Records
    Hardeep Singh, MD, MPH; Dean F. Sittig, PhD; Maureen Layden, MD, MPH| November 1, 2010
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    • At two different hospitals, patients were instructed to continue home medications, even though their medication lists had errors that could have led to significant adverse consequences.
    Hospital Admission Due to High-Dose Methotrexate Drug Interaction
    Lydia C. Siegel, MD; Tejal K. Gandhi, MD, MPH| January 1, 2009
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    • Four months after surgery, a woman with osteosarcoma receiving outpatient chemotherapy was admitted for possible cellulitis. Discharged home on methotrexate and antibiotics, the patient developed methotrexate toxicity, partly due to a drug interaction.
    Recurrent Hypoglycemia: A Care Transition Failure?
    Ted Eytan, MD, MS, MPH| October 1, 2008
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    • An elderly, non–English-speaking man with diabetes was admitted to the hospital twice in 8 days due to hypoglycemia. At discharge, the patient was instructed not to take any antidiabetic medications. In between hospitalizations, he saw his primary care physician, who restarted an antidiabetic medication.
    One ACE Too Many
    David N. Juurlink, BPhm, MD, PhD| July 1, 2006
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    • A patient presenting to the ED with chest pain was ruled out for MI, and discharged on an ACE inhibitor. Two weeks later, he returns with a critically elevated potassium level, has a cardiac arrest, and dies.
    Language Barrier
    Glenn Flores, MD| April 1, 2006
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    • With no one to interpret for them and pharmacy instructions printed only in English, non–English-speaking parents give their child a 12.5-fold overdose of a medication.
    A "Weak" Response
    Anna B. Reisman, MD| December 1, 2004
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    • Feeling "weak" late at night, a patient calls his doctor's office. The covering physician misses a few clues, which might have prompted a different plan.
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