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: November 16, 2022
Nasim Hedayati, MD, and Richard White, MD | November 16, 2022

A 61-year-old women with a mechanical aortic valve on chronic warfarin therapy was referred to the emergency department (ED) for urgent computed tomography (CT) imaging of the right leg to rule out an arterial clot. CT imaging revealed two... Read More

Leilani Schweitzer | November 16, 2022

A 58-year-old man underwent a complex surgery to replace his aortic valve. The surgery required prolonged cardiopulmonary bypass time and cross-clamp time and there was a short delay in redosing the cardioplegic solution and the patient developed ... 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 (6)

Displaying 1 - 6 of 6 WebM&M Case Studies
Garima Agrawal, MD, MPH, Pouria Kashkouli, MD, MS, and and Deb Bakerjian PhD, APRN, FAAN, FAANP, FGSA| July 8, 2022

This WebM&M describes a 78-year-old veteran with dementia-associated aggressive behavior who was hospitalized multiple times over several months for hypoxic respiratory failure and atrial fibrillation before being discharged to a skilled nursing facility. The advanced care planning team, in consultation with palliative care and ethics experts, determined that transition to hospice was appropriate. However, these recommendations were verbally communicated and not documented in the chart. The patient developed acute hypoxic respiratory failure the night prior to the planned transition to hospice, was re-admitted to the hospital, and passed away three weeks later at the hospital. The commentary discusses the importance of well-coordinated transitions of care and the importance of active communication and standardized documentation during palliative care transitions.

Elinore F. McCance-Katz, MD, PhD| October 1, 2012
A man with a long history of opioid dependence (and smoking) went to a substance abuse program for detoxification. The patient received buprenorphine/naloxone and was found unresponsive and cyanotic a few hours later. He was diagnosed with opiate-induced respiratory distress complicated by pneumonia and chronic obstructive pulmonary disease.
Christopher Fee, MD| March 21, 2009
Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.
Joan M. Teno, MD, MS| April 1, 2008
Despite having a signed DNR (do not resuscitate) form, an elderly man brought to the emergency department with severe pain was rushed to the operating room for urgent abdominal aortic aneurysm repair.
Mark A. Crowther, MD, MSc| July 1, 2003
Inadequate monitoring and management of warfarin places patient at significant risk of harm.
Sidney T. Bogardus, Jr., MD| April 1, 2003
Delirious and coagulopathic patient with subdural hematomas falls out of bed—twice!