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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: September 27, 2023
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 (621)

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Displaying 1 - 20 of 621 Results
Leah Timbag, MD, MPH, Voltaire R. Sinigayan, MD, and Mithu Molla, MD, MBA | September 27, 2023

This case describes the failure to identify a brewing abdominal process, which over the span of hours led to fulminant sepsis with rapid clinical deterioration and eventual demise. The patient’s ascitic fluid cultures and autopsy findings confirmed bowel perforation, but this diagnosis was never explicitly considered. The commentary discusses the importance of early identification of sepsis, the role of biomarkers and risk scores in conjunction with bedside examinations to assess patients with suspected sepsis, and approaches to improve the prognosis of patients in septic shock, such as protocolized sepsis bundles.

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Commentary by James A. Bourgeois, OD, MD and Glen Xiong, MD | September 27, 2023

A 42-year-old man with a history of posttraumatic stress disorder (PTSD), alcohol use disorder and anxiety disorder, was seen in the emergency department (ED) after a high-risk suicide attempt by hanging. The patient was agitated and attempted to escape from the ED while on an involuntary psychiatric commitment. The ED staff treated him as a “routine boarder” awaiting an inpatient bed, with insufficiently robust behavioral monitoring. He eloped, then further complications resulted when law enforcement personnel were involved in his psychiatric emergency and when correctional mental health services were not available in a timely manner. The commentary discusses the importance of assessing for hypoxia-associated delirium and/or hippocampal damage/amnesia after any strangulation and the need for inpatient psychiatric hospitalization after emergency stabilization and management of delirium

Hana Camarillo, PharmD, BCACP, CDCES| September 27, 2023

A 14-year-old girl was admitted to the hospital with a new diagnosis of type 1 diabetes mellitus without ketoacidosis. Before discharge, medications intended for home use were delivered to the patient’s bedside, but the resident physician noticed a discrepancy. An insulin pen and pen needles had been ordered, but an insulin vial and extra insulin syringes were delivered. Neither the patient nor the parents had received education on how to draw up and administer insulin using a vial and syringe. The pharmacy staff reported that the insulin pen was out of stock, so the insulin vial was substituted because it contained the same active ingredient. The insulin product switch was declined, and another pharmacy was contacted to provide the insulin pen, which was delivered to the patient’s bedside the following day. The commentary summarizes the patient safety risks associated with drug shortages, drug interoperability standards, and the importance of clear communication between members of the care team if alternative therapies need to be considered

Commentary by Alyssa Bellini, MD and Edgardo S Salcedo, MD, FACS| September 27, 2023

This case highlights two “never events” involving the same patient. A first-year orthopedic surgery resident was consulted to aspirate fluid from the left ankle of a patient in the intensive care unit. The resident, accompanied by a second resident, approached the wrong patient and inserted the needle into the patient’s right ankle. At this point, a third resident entered the room and stated that it was the incorrect patient. The commentary highlights the importance of a proper time out and approaches to improve communication among all members of the care team.

Liliya Klimkiv, MD, Garth Utter, MD, MSc, and David K. Barnes, MD| September 27, 2023

This case describes an older adult patient with generalized abdominal pain who was eventually diagnosed with inoperable bowel necrosis. Although she appeared well and had stable vital signs, triage was delayed due to emergency department (ED) crowding, which is usually a result of hospital crowding. She was under-triaged and waited three hours before any diagnostic studies or interventions commenced. Once she was placed on a hallway gurney laboratory and imaging studies proceeded hastily. Catastrophic bowel necrosis was eventually identified, yet she was not moved to a standard ED treatment bed for another 25 minutes. Despite aggressive resuscitation, the surgeon determined that operative intervention was futile, and the patient died a short time later. The commentary highlights how hospital crowding and ED boarding can lead to delayed triage and inefficient ED throughput, which compromises patient safety and summarizes approaches to improving ED triage and throughput.

Sarah Marshall, MD and Nina M. Boe, MD| August 30, 2023

A 31-year-old pregnant patient with type 1 diabetes on an insulin pump was hospitalized for euglycemic diabetic ketoacidosis (DKA). She was treated for dehydration and vomiting, but not aggressively enough, and her metabolic acidosis worsened over several days. The primary team hesitated to prescribe medications safe in pregnancy and delayed reaching out to the Maternal Fetal Medicine (MFM) consultant, who made recommendations but did not ensure that the primary team received and understood the information. The commentary highlights how breakdowns in communication amongst providers can lead to medical errors and prolonged hospitalization and how the principles of team-based care, communication, and a culture of safety can improve care in complex health care situations.

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By Christian Bohringer, MBBS, and Ryan Osborne, MD| August 30, 2023

This case describes a 27-year-old primigravid woman who requested neuraxial anesthesia during induction of labor. The anesthesia care provider, who was sleep deprived near the end of a 48-hour call shift (during which they only slept for 3 hours), performed the procedure successfully but injected an analgesic drug that was not appropriate for this indication. As a result, the patient suffered slower onset of analgesia and significant pruritis, and required more prolonged monitoring, than if she had received the correct medication. The commentary discusses the implications of sleep deprivation, especially in high-risk settings such as anesthesia care and obstetric care, and approaches to improve patient safety during labor and delivery.

Theresa Duong, MD, Noelle Boctor, MD, and James Bourgeois, OD, MD| July 31, 2023

This case describes a 65-year-old man with alcohol use disorder who presented to a hospital 36 hours after his last alcoholic drink and was found to be in severe alcohol withdrawal. The patient’s Clinical Institute Withdrawal Assessment (CIWA) score was very high, indicating signs and symptoms of severe alcohol withdrawal. He was treated with symptom-triggered dosing of benzodiazepines utilizing the CIWA protocol and dexmedetomidine continuous infusion. The treating team had planned to wean the infusion; however, the following day, the patient was noted to be obtunded on a high dose of dexmedetomidine. He remained somnolent for two additional days and subsequently developed aspiration pneumonia and Clostridioides difficile colitis, which further prolonged his hospital stay and strained relationships among the patient's family, the nursing staff and medical team. The commentary reviews the medications commonly used to treat alcohol withdrawal and the risks associated with these medications, the use of standardized medication order sets for continuous weight-based infusions within the intensive care unit, and ways to minimize clinician bias in assessing and treating substance use disorders.

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Sean Flynn, MD and David K. Barnes, MD, FACEP| July 31, 2023

A 56-year-old woman presented to the emergency department (ED) with shaking, weakness, poor oral intake and weight loss, constipation for several days, subjective fevers at home, and mild pain in the chest, back and abdomen. An abdominal x-ray confirmed a large amount of stool in the colon with no free air and her blood leukocyte count was 11,500 cells/μL with 31% bands. She received intravenous fluids but without any fecal output while in the ED. She was discharged to home with a diagnosis of constipation, dehydration and failure to thrive and planned follow-up with her primary care provider. Three days later, she was admitted to a second hospital and the surgeon found stercoral colitis and a large perforated “stercoral ulcer” of the proximal sigmoid colon with disseminated fecal and purulent material. Despite aggressive surgical and postoperative care, she expired from sepsis ten days later. The commentary summarizes the diagnosis and management of stercoral colitis and the importance of prompt identification of bandemia, which should trigger further investigation for an underlying infection.

Christian Bohringer, MBBS, James Bourgeois, OD, MD, Glen Xiong, MD, and Emily Wei, MD| July 31, 2023

A 50-year-old unhoused patient presented to the Emergency Department (ED) for evaluation of abdominal pain, reportedly one day after swallowing multiple sharp objects. Based on the radiologic finding of an open safety pin or paper clip in the distal stomach, he was appropriately scheduled for urgent esophagogastroduodenoscopy and ordered to remain NPO (nothing by mouth) to reduce the risk of aspirating gastric contents. However, the order was not communicated verbally and he was allowed to eat, leading to postponement of the procedure and ultimately to an unsatisfactory conclusion with discharge of the patient against medical advice. This case raises interesting questions about the evaluation and treatment of pica in the ED, the communication of dietary status information, the risks of procedural sedation in a non-fasting patient, and the evaluation of decisional capacity in a patient with recurrent pica.

Elizabeth Gould, NP-C, CORLN, Kathleen M Carlsen, PA, Brooks T Kuhn, MD, MAS, and Jonathan Trask, RN| June 28, 2023

A 56-year-old man was admitted to the hospital and required mechanical ventilation due to COVID-19-related pneumonia and acute respiratory failure. The care team performed a tracheostomy percutaneously at the bedside with some difficulty. The tracheostomy tube was secured, inspected via bronchoscopy, and properly sutured. During the next few days, the respiratory therapist noticed a leak that required additional inflation of the cuff to maintain an adequate seal. Before the care team could change the tracheostomy, the tracheal cuff burst, and the patient developed hypotension and required 100% inhaled oxygen via the ventilator. The commentary summarizes best practices regarding proper tracheostomy tube choice and sizing to prevent leaks around cuffs, the importance of staff education on airway cuff pressure monitoring, and the role of multidisciplinary tracheostomy teams to optimize tracheostomy care.

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Tai Huu Pham, MD and Surabhi Atreja, MD | June 28, 2023

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.

Christian Bohringer, MBBS and Griffin Lee, MD| June 28, 2023

A 55-year-old man presented in hypotensive shock, presumably due to bacterial pneumonia superimposed on COPD. The nurse placed an arterial line appropriately in the patient’s radial artery for hemodynamic monitoring, but this line was inadvertently used to infuse an antibiotic. The patient experienced acute arterial thrombosis with resulting hand ischemia but responded to rapid thrombolytic and anticoagulant therapy. The commentary highlights several approaches to improving the safety of arterial injections, including the use of color-coded and Luer-specific connections, clear labeling of arterial lines, and the importance of monitoring arterial and central line pressures for signs of ischemia.


A 25-year-old obese patient required an emergency cesarean delivery. As the obstetric team was in a hurry to deliver the baby, the team huddle was rushed. After the delivery, the anesthesia care provider discovered that the patient had received subcutaneous enoxaparin 40 mg four hours preoperatively, which was not mentioned by the obstetric team during the previous huddle. The patient developed a dense, persistent motor and sensory block of the lower limbs at 6 to 8 hours after delivery, which gradually wore off and the patient recovered without any permanent sensory or motor impairment. The commentary highlights the importance of preoperative huddles and pre-incision time out checklists to improve patient outcomes as well as the role of emergency cesarean simulation training for obstetric, anesthesia and nursing care teams.

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Mimmie Kwong, MD, MAS| June 28, 2023

A 66-year-old woman presented to the emergency department (ED) and was initiated on antibiotics and received fluid resuscitation for suspected urinary sepsis versus recurrent C. difficile colitis. However, the physical examination omitted an examination of her legs. Due to hospital overcrowding, the patient was kept in the ED overnight.

During her stay in the ED, the patient had persistent hypotension requiring norepinephrine infusion for approximately 12 hours. However, vital signs were notably absent from the medical record, with an 8-hour period during vasopressor administration in which no blood pressure measurements or limb assessments were recorded by nursing staff. After vasopressor administration ended, the primary service noted that the patient had cool lower extremities and no palpable pulses. A Vascular Surgery consultant determined that she had Rutherford Grade 3 ischemia and her limbs were non-salvageable; she underwent bilateral above knee amputations (AKA). Th commentary discusses the risk of limb ischemia in the setting of sepsis and peripheral vasoconstriction from pressor use, particularly among patients with underlying peripheral arterial disease, and the importance of close hemodynamic monitoring and timely intervention in patients with septic shock despite limitations created by ED and hospital overcrowding.

Noelle Boctor, MD, and Mithu Molla, MD, MBA| June 14, 2023

A 63-year-old man presented from a skilled nursing facility (SNF) with shortness of breath and was treated for mild heart failure exacerbation. An echocardiogram was performed but results were pending on discharge, with anticipation that the patient’s primary care provider would follow up the results. Two weeks later, the patient was readmitted from the SNF and was found to have endocarditis and infected pacemaker wires. The admitting physician reviewed the echocardiogram from the prior hospitalization and noted there was a vegetation on the tricuspid valve, which was an unexpected finding. Since the echocardiogram results had populated into the electronic health record after the patient was discharged, the result of the new vegetation was not flagged and no providers were contacted about this finding by the cardiologist who read the echocardiogram. Using the systems-based Swiss cheese model, the commentary discusses errors during transitions of care and strategies to decrease the number of figurative Swiss cheese holes, including checklists and structured handoffs, as well as effective communication regarding critical results.

Garima Agrawal, MD, MPH, and Diana Mai Nguyen, MD | June 14, 2023

An elderly patient (Patient A) with a recent diagnosis of B cell lymphoma with central nervous system (CNS) involvement was discharged home with the home medications belonging to his hospital roommate (Patient B). By the time his family had discovered the error, Patient A had taken three doses of the incorrect prescription. An investigation revealed that both patients brought their own unique home medications which were not on the hospital’s formulary, and Patient A was inadvertently given both his home bag of medications and Patient B’s. The commentary discusses the safety risks present when home medications are brought to the hospital for administration during the hospitalization.

James A. Bourgeois, OD, MD, Glen Xiong, MD, David K. Barnes, MD and Rupinder Sandhu, RN, MBA| June 14, 2023

A 25-year-old female was sent by ambulance to the emergency department (ED) by a mental health clinic for suicidal ideation. Upon arrival to the ED, she was evaluated by the triage nurse and determined to be awake, alert, calm, and cooperative and she denied current suicidal thoughts. The ED was extremely busy, and the patient was placed on a gurney with a Posey restraint in the hallway next to the triage station awaiting psychiatric social work assessment. Approximately 40 minutes later, the triage nurse noticed that the patient was missing from the gurney. Eight minutes later, the patient was found by a staff member in a bathroom in the radiology department adjacent to the ED. She was on the floor with her shoestrings tied around her neck. She was awake and breathing and was returned to the ED resuscitation room where she was evaluated by the physician. The commentary discusses the importance of timely psychiatric assessment, appropriate use of restraints and direct 1:1 observation, and how ED overcrowding compounds existing challenges in emergency medical care.  

Commentary by Michael Leonardo Amashta, MD, and David K. Barnes, MD, FACEP | April 26, 2023

This case involves a procedural sedation error in a 3-year-old patient who presented to the Emergency Department with a left posterior hip dislocation. The commentary summarizes the indications and risks of procedural sedation in non-surgical settings and highlights the value of implementing system-wide safety protocols and practices to prevent medication administration errors during high-risk procedures.

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