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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: October 30, 2024
Spotlight Case
CE/MOC
New
Garth Utter, MD | October 30, 2024
A 38-year-old man sustained multiple injuries in a motorcycle crash, including head trauma, chest injuries, and spinal... Read More
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Spotlight Case
CE/MOC
New
Ryan Martin, MD, FCNS and Kiarash Shahlaie, MD, PhD, FAANS, FCNS | October 30, 2024
A man in his mid-50s presented to the hospital with a persistent headache after a sledding injury. A head CT scan was read as... Read More
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Victoria Jackson, DNP, RN, PHN, FNP-C, PA-C and Anna Satake, PhD, MSN, GCNS, RN | October 30, 2024
These cases involve two elderly patients presenting to the emergency department (ED) who suffered falls during their care, despite recognition of risk factors including previous... 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 (662)
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Displaying 521 - 540 of 662 Results
Displaying 521 - 540 of 662 Results
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Niraj L. Sehgal, MD, MPH|
February 1, 2007
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A parent brings her 18-month-old into the clinic with multiple complaints, including rash, diarrhea, and concern for fracture due to a fall. The child is sent home with a diagnosis of viral syndrome. Later, still concerned about her child's gait, the mother takes her to the ED, where an x-ray reveals a fractured tibia.
Michael Astion, MD, PhD |
December 1, 2006
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A man admitted to the hospital for elective surgery has blood drawn. Despite a policy for proper identification, the blood samples were all mislabeled with another patient's name. The error was discovered at the lab, and there was no harm to the patient.
John M. Oldham, MD|
December 1, 2006
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A young woman with borderline personality disorder hospitalized following a suicide attempt is allowed to leave the hospital and attempts suicide again.
Patrick F. Fogarty, MD|
December 1, 2006
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A hospitalized woman with multiple medical problems is diagnosed with heparin-induced thrombocytopenia (HIT) but is mistakenly exposed to heparin flushes during dialysis.
Jonathan S. Jahr, MD; Puya Hosseini|
November 1, 2006
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An elderly woman underwent knee replacement, during which her airway was maintained with a laryngeal mask airway. However, she developed a fever and fullness in her neck, which a CT scan revealed to be retropharyngeal and mediastinal abscesses.
Angela C. Joseph, RN, MSN, CURN|
November 1, 2006
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Following elective surgery, a man with benign prostatic hypertrophy began having trouble with urination. Delay in addressing this issue caused discomfort and the need for catheterization and antibiotics.
Peter Lindenauer, MD, MSc|
November 1, 2006
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A woman with end stage renal disease and heart disease on anticoagulation receives a pneumonia vaccination that causes a large hematoma.
Elizabeth A. Flynn, PhD|
September 1, 2006
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A woman admitted for heart and respiratory failure is mistakenly given penicillamine (a chelating agent) rather than penicillin (an antibiotic).
Bernard Lo, MD|
September 1, 2006
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An elderly woman who had a DNR in place took a fall that required her to have surgery. Discussion with the patient's health care proxy led to the DNR order being suspended during surgery, with the understanding that it would be reinstated postoperatively. Several days later, a nurse noticed that patient remained 'full code' because the DNR had not been restored.
Arpana R. Vidyarthi, MD|
September 1, 2006
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An elderly man was admitted to the hospital for pacemaker placement. Although the postoperative chest film was normal, the patient later developed shortness of breath. Over the course of several nursing and physician shift changes and signouts, results of a follow-up stat x-ray are not properly obtained, delaying discovery of the patient's pneumothorax.
Saul N. Weingart, MD, PhD|
August 1, 2006
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In the office, a man with diabetes has high blood sugar, and the nurse practitioner orders insulin. After administration, she discovers that she has injected the insulin with a tuberculin syringe rather than an insulin syringe, resulting in a 10-fold overdose.
Scott A. Strassels, PharmD, PhD, BCPS|
August 1, 2006
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In anticipation of discharge, a patient's opiate medication is changed from an immediate-release to a long-acting formbut the dose was incorrectly converted, resulting in an overdose. The patient develops respiratory distress and requires a 2-week stay in the ICU.
George R. Thompson III, MD, and Abraham Verghese, MD|
August 1, 2006
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A man with paraplegia was admitted to the hospital, but the admitting physician, night float resident, and daytime team all "deferred" examination of the genital area. The patient was later discovered to have life-threatening necrotizing fasciitis of this area.
Russ Cucina, MD, MS|
July 1, 2006
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Despite full documentation and a wristband regarding her severe food allergy, an inpatient is advertently fed eggs and suffers an allergic reaction.
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.
Hildy Schell, RN, MS, CCNS; Robert M. Wachter, MD|
July 1, 2006
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An elderly woman was transported to CT with no medical escort and an inadequate oxygen supply. She died later that day.
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.
Robert J. Weber, MS, RPh|
May 1, 2006
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A pharmacist mistakenly dispenses Polycitra instead of Bicitra, and a patient winds up with severe hyperkalemia and hyperglycemia.
Mary A. Blegen, PhD, RN; Ginette A. Pepper, PhD, RN|
May 1, 2006
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A nursing student administers the wrong 'cup' of medications to an elderly man. A different student discovered the error when she reviewed the medicines in her patient's cup and noticed they were the wrong ones.
Philip Darney, MD, MSc|
April 1, 2006
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A woman has an intrauterine contraceptive device placed at the time of "her period." A month later it is discovered that she is pregnant, as she had been at the time of the insertion.
