WebM&M: Case Studies

During an elective diagnostic cardiac catheterization, the cardiologist unintentionally perforated the patient’s left ventricular wall with the catheter. The cardiologist failed to recognize the perforation, failed to take corrective measures to address the problem, and continued with the cardiac catheterization, including coronary angiographic imaging. Soon after the end of the procedure, the patient complained of severe chest pain and echocardiographic images revealed bleeding around the heart caused by the catheter-related ventricular wall perforation. The patient underwent emergency exploratory surgery to fix the perforation within 40 minutes thereafter, but he did not survive. The commentary discusses the risks associated with diagnostic cardiac catheterization due to both patient- and operator-related factors and the importance of effective team communication and immediate recognition of iatrogenic injuries.

This WebM&M describes two cases involving patients who became unresponsive in unconventional locations – inside of a computed tomography (CT) scanner and at an outpatient transplant clinic – and strategies to ensure that all healthcare teams are prepared to deliver advanced cardiac life support (ACLS), such as the use of mock codes and standardized ACLS algorithms.

A man with end-stage renal disease on hemodialysis was dialyzed with equipment that had been inappropriately reused, exposing the patient to another patient's blood numerous times.

A man sent for a Holter monitor inadvertently arrives at the allergy clinic and receives a skin test instead.

A child is mistakenly vaccinated for hepatitis A, rather than B. Despite forthright disclosure and no evident harm to the child, the father becomes incredibly angry at the providers.

A physician in the ED mistakenly glues a child's eye shut when attempting to close a facial wound with skin adhesive.