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
A 67-year-old man with well-controlled type 2 diabetes mellitus underwent elective cardiac... Read More
A 38-year-old woman with class 3 obesity required removed of a gastric balloon under general anesthesia.... Read More
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
This case describes a 55-year-old woman who sustained critical injuries after a motor vehicle crash and had a lengthy... Read More
All WebM&M: Case Studies (6)
A 71-year-old man presented to a hospital-based orthopedic surgery clinic for a follow-up evaluation of his knee and complaints of pain and swelling in his right shoulder. His shoulder joint was found to be acutely inflamed and purulent fluid was aspirated from his shoulder. The patient was sent to the Emergency Department (ED) for suspected septic arthritis. Although the inpatient team was made aware of the incoming patient and admission orders were entered into the electronic health record (EHR) before ED arrival, ED staff were not informed of the incoming patient or the orthopedic surgeon’s plan for immediate admission. When the patient arrived, there were multiple patients in the ED waiting room and multiple boarding patients awaiting inpatient beds. The patient stayed in the ED hallway on “wall time” under the care of the Emergency Medical Services (EMS) personnel; no ED physician or nurse was assigned to evaluate or care for the patient because the transfer of care from EMS had not occurred. The patient was on wall time for at least 10 hours before any actions were taken by the ED before being admitted to the orthopedic inpatient service. The commentary discusses challenges associated with ED transfers and ED overcrowding, potential system-level solutions to the “wall time” problem, and the importance of closed-loop communication.
A 2-year-old girl presented to her pediatrician with a cough, runny nose, low grade fever and fatigue; a nasal swab for SARS-CoV-2 and influenza was negative and lung sounds were clear. The patient developed a fever and labored breathing and was taken to the Emergency Department (ED) before being admitted to the hospital. She developed respiratory distress and clinically worsened over time until she developed respiratory failure requiring air transportation to the pediatric intensive care unit at a children’s hospital. She was ultimately diagnosed with adenovirus after developing conjunctivitis and bronchiolitis. After 3 days of continuous monitoring and treatment in the PICU, the patient was alert, responsive, and hungry. She was taken off supplemental oxygen after about 24 more hours, transferred to a regular pediatric bed, and then discharged to outpatient follow-up care. The commentary addresses patient safety risks associated with pediatric interfacility transfers and strategies to mitigate preventable harms due to poor provider-provider communication, provider-family communication, and family engagement.
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 unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.