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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 28, 2022
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 (16)

1 - 16 of 16 WebM&M Case Studies

A 61-year-old male was admitted for a right total knee replacement under regional anesthesia. The surgeon – unaware that the anesthesiologist had already performed a right femoral nerve block with 20 ml (100mg) of 0.5% racemic bupivacaine for postoperative analgesia – also infiltrated the arthroplasty wound with 200 mg of ropivacaine. The patient was sedated with an infusion of propofol throughout the procedure. At the end of the procedure, after stopping the propofol infusion, the patient remained unresponsive, and the anesthesiologist diagnosed the patient with Local Anesthetic Systemic Toxicity (LAST). The commentary addresses the symptoms of LAST, the importance of adhering to local anesthetic dosing guidelines, and the essential role of effective communication between operating room team members.

Stephanie Rogers, MD, and Derek Ward, MD| April 1, 2019
An elderly man with a complicated medical history slipped on a rug at home, fell, and injured his hip. Emergency department evaluation and imaging revealed no head injury and a left intertrochanteric hip fracture. Although he was admitted to the orthopedic surgery service, with surgery to fix the fracture initially scheduled for the next day, the operation was delayed by 3 days due to several emergent trauma cases and lack of surgeon availability. He ultimately underwent surgery and was discharged a few days later but was readmitted several weeks later with chest pain and shortness of breath. He was found to have a pulmonary embolism; anticoagulation was initiated. The patient's rehabilitation was delayed, his recovery was prolonged, and he never returned to his baseline functional status.
Jeanna Blitz, MD| November 1, 2018
When patients in two cases did not receive complete preanesthetic evaluation, problems with intubation ensued. In the first case, an anesthesiologist went to evaluate a morbidly obese patient scheduled for hysteroscopy. As the patient was donning her hospital gown behind a closed curtain, he waited but left without performing the preoperative assessment because the morning surgery list was overbooked and he had many other patients to see. Once in the operating room, he discovered on chart review that the woman had a history of gastroesophageal reflux. She could not be intubated, and a supraglottic airway was placed. In the second case, an elderly man with a tumor mass at the base of his tongue was scheduled for a biopsy. On examination, the anesthesiologist could not see much of the mass with the patient's mouth maximally open and tongue sticking out, and he couldn't locate the patient's head and neck CT to further evaluate the mass. The surgeon arrived late and did not communicate with the anesthesiologist about the patient. After inducing general anesthesia, laryngoscopy and intubation proved extremely difficult as the mass obscured the view of the larynx. A second anesthesiologist was called, and together they were able to intubate the patient with a fiberoptic bronchoscope.
Jeffrey Jim, MD, MPHS| August 1, 2018
An older man with multiple medical conditions and an extensive smoking history was admitted to the hospital with worsening shortness of breath. He underwent transthoracic echocardiogram, which demonstrated severe aortic stenosis. The cardiology team recommended cardiac catheterization, but the interventional cardiologist could not advance the catheter and an aortogram revealed an abdominal aortic aneurysm (AAA) measuring 9 cm in diameter. Despite annual visits to his primary care physician, he had never undergone screening ultrasound to assess for presence of an AAA. The patient was sent emergently for surgical repair but had a complicated surgical course.
John Starling III, MD| March 1, 2012
Following biopsies for two skin lesions on his left cheek, a patient was sent to an outside surgeon for excision of squamous cell carcinoma. Although the referral included a description and diagram, the wrong lesion was removed.
Richard A. Smith, DDS| August 21, 2007
A patient underwent tooth extraction, but awoke from anesthesia and found that the wrong two teeth had been removed.
B. Joseph Guglielmo, PharmD| March 1, 2007
Several days after a patient’s surgery, preliminary wound cultures grew Staphylococcus aureus. Although the final sensitivity profile for the cultures showed resistance to the antibiotic that the patient was receiving, the care team was not notified and the patient died of sepsis.
Angela C. Joseph, RN, MSN, CURN| November 1, 2006
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.
Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD, MPP, MPH| May 1, 2006
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.
Nils Kucher, MD| January 1, 2006
Following reconstructive surgery to her hand, a woman suffers sudden cardiopulmonary arrest. After successful resuscitation, further review revealed that she had a pulmonary embolism and that she had received no venous thromboembolism prophylaxis.
Tracy Minichiello, MD| March 1, 2005
Despite a box on the admission form warning against using blood thinners and epidural anesthesia together, a patient admitted for elective surgery receives both, and becomes permanently paralyzed.
Stephen G. Pauker, MD; Susan P. Pauker, MD| May 1, 2004
Owing to privacy concerns, a nurse draws the drapes on a 3-year-old child in recovery following surgery, and unfortunately does not realize the child is in distress until loud inspiratory stridor is heard.
Haya R. Rubin, MD, PhD; Vera T. Fajtova, MD| May 1, 2004
To achieve tight glucose control, a hospitalized diabetes patient is placed on an insulin drip. Prior to minor surgery, he is made NPO and becomes severely hypoglycemic.
Darren R. Linkin, MD; Ebbing Lautenbach, MD, MPH, MSCE| February 1, 2004
Infection Control notices an uptick in post-operative wound infections for patients from one OR team. Environmental rounds reveal "sloppy" practices.
Charles Vincent, PhD| October 1, 2003
Trusting his memory more than the chart, a surgeon directs a resident to remove the wrong side on a patient with unilateral vulvar cancer.
Linda D. Bradley, MD| September 1, 2003
Following surgical team's makeshift assembly of equipment, a patient undergoing hysteroscopy suffers cardiac arrest on the OR table.