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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: August 5, 2022
Samson Lee, PharmD, and Mithu Molla, MD, MBA | August 5, 2022

This WebM&M highlights two cases where home diabetes medications were not reviewed during medication reconciliation and the preventable harm that could have occurred. The commentary discusses the importance of medication reconciliation, how to... 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 (44)

1 - 20 of 44 WebM&M Case Studies
Nandakishor Kapa, M.D., and José A. Morfín, M.D.| February 23, 2022

A 69-year-old man with End-Stage Kidney Disease (ESKD) secondary to diabetes mellitus and hypertension, who had been on dialysis since 2014, underwent deceased donor kidney transplant. The case demonstrates the complex nature of management of allograft dysfunction due to vascular complications in a patient with deceased donor kidney transplant in the early post-transplant period. The commentary discusses how standardized follow-up imaging protocols can support early recognition and evaluation of allograft dysfunction due to vascular complications in kidney transplant recipients, as well the importance of team communication for patients requiring multiple interventions to reduce lag time in addressing further complications.

This case involves a 2-year-old girl with acute myelogenous leukemia and thrombocytopenia (platelet count 26,000 per microliter) who underwent implantation of a central venous catheter with a subcutaneous port. The anesthetist asked the surgeon to order a platelet transfusion to increase the child’s platelet count to above 50,000 per microliter. In the post-anesthesia care unit, the patient’s arterial blood pressure started fluctuating and she developed cardiac arrest. A “code blue” was called and the child was successfully resuscitated after insertion of a thoracostomy drainage (chest) tube. Unfortunately, the surgeon damaged an intercostal artery when he inserted the chest tube emergently, which caused further bleeding and two additional episodes of PEA arrest. This commentary addresses the importance of mitigating risk during procedures, balancing education of proceduralist trainees with risk to the patient, and prompt review of diagnostic studies by qualified individuals to identify serious complications.

A seven-year-old girl with esophageal stenosis underwent upper endoscopy with esophageal dilation under general anesthesia. During the procedure, she was fully monitored with a continuous arterial oxygen saturation probe, heart rate monitors, two-lead electrocardiography, continuous capnography, and non-invasive arterial blood pressure measurements. The attending gastroenterologist and endoscopist were serially dilating the esophagus with larger and larger rigid dilators when the patient suddenly developed hypotension. She was immediately given a fluid bolus, phenylephrine, and 100% oxygen but still developed cardiac arrest. Cardiopulmonary resuscitation was initiated with cardiac massage, but she could not be resuscitated and died. This commentary highlights the role of communication between providers, necessary technical steps to mitigate the risks of upper endoscopy in children, and the importance of education and training for care team members.

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.

Two separate patients undergoing urogynecologic procedures were discharged from the hospital with vaginal packing unintentionally left in the vagina. Both cases are representative of the challenges of identifying and preventing retained orifice packing, the critical role of clear handoff communication, and the need for organizational cultures which encourage health care providers to communicate and collaborate with each other to optimize patient safety.

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By Gary S. Leiserowitz, MD, MS and Herman Hedriana, MD| November 25, 2020

After a failed induction at 36 weeks, a 26-year-old woman underwent cesarean delivery which was complicated by significant postpartum hemorrhage. The next day, the patient complained of severe perineal and abdominal pain, which the obstetric team attributed to prolonged pushing during labor. The team was primarily concerned about hypotension, which was thought to be due to hypovolemia from peri-operative blood loss. After several hours, the patient was transferred to the medical intensive care unit (ICU) with persistent hypotension and severe abdominal and perineal pain. She underwent surgery for suspected necrotizing fasciitis, but necrosis was not found. The patient returned to the surgical ICU but deteriorated; she returned to the operating room, where she was found to have necrotizing soft tissue infection, including in the flanks, labia, and uterus. She underwent extensive surgery followed by a lengthy hospital stay. The accompanying commentary discusses the contribution of knowledge deficits and cognitive biases to diagnostic errors and the importance of structured communications between professionals.

Christi DeLemos, MSN, CNRN, ACNP-BC | October 28, 2020

A 73-year-old female underwent a craniotomy and aneurysm clipping to resolve a subarachnoid hemorrhage due to a ruptured aneurysm. The neurosurgery resident confirmed the presence of neuromonitoring with the Operating Room (OR) front desk but the neuromonitoring technician never arrived and the surgeon – who arrived after the pre-op huddle – decided to proceed with the procedure in their absence. Although no problems were identified during surgery, the patient emerged from anesthesia with left-sided paralysis, and post-op imaging showed evidence of a new stroke. The commentary discusses the importance of huddles, ensuring closed-loop communication involving residents, and balancing benefits and risks during emergent surgical care.

Richard P. Dutton, MD MBA| August 26, 2020

A 40-year-old man with multiple comorbidities, including severe aortic stenosis, was admitted for a pathologic pelvic fracture (secondary to osteoporosis) after a fall. During the hospitalization, efforts at mobilization led to a second fracture of the left femoral neck The case describes deviations in the plan for management of anesthesia and postoperative care which ultimately contributed to the patient’s death. The commentary discusses the importance of multidisciplinary planning for frail patients, the contributors to, and consequences of, deviating from these plans, and the use of triggers, early warning systems, and rapid response teams to identify and respond to early signs of decompensation.

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Sierra Rayne Young, Pharm.D. and Iris Chen, Pharm.D., BCPS| November 27, 2019
Three patients were at the same hospital over the course of a few months for vascular access device (VAD) placement and experienced adverse outcomes. The adverse outcomes of two of them were secondary to drugs given for sedation, while the third patient’s situation was somewhat different. Vascular access procedures are extremely common and are relatively short but may require the use of procedural sedation, which is usually very well tolerated but can involve significant risk, as these cases illustrate.
Audrey Lyndon, PhD, RN, and Stephanie Lim, MD| June 1, 2019
During surgery for a forearm fracture, a woman experienced a drop in heart rate to below 50 beats per minute. As the consultant anesthesiologist had stepped out to care for another patient, the resident asked the technician to draw up atropine for the patient. When the technician returned with an unlabeled syringe without the medication vial, the resident was reluctant to administer the medication, but did so without a double check after the technician insisted it was atropine. Over the next few minutes, the patient's blood pressure spiked to 250/135 mm Hg.
John Day and John T. Paige, MD| May 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.
Lina Bergman, RN, MSc, and Wendy Chaboyer, RN, PhD| February 1, 2019
Following surgery under general anesthesia, a boy was extubated and brought to postanesthesia care unit (PACU). Due to the patient's age and length of the surgery, the PACU anesthesiologist ordered continuous pulse-oximetry monitoring for 24 hours. Deemed stable to leave the PACU, the boy was transported to the regular floor. When the nurse went to place the patient on pulse oximetry, she realized he was markedly hypoxic. She administered oxygen by face mask, but he became bradycardic and hypotensive and a code blue was called.
Ken Catchpole, PhD| August 1, 2017
Because the plan to biopsy a large gastric mass concerning for malignancy was not conveyed to the hospitalist caring for the patient, she was not made NPO, nor was her anticoagulant medication stopped. The nurse anesthetist performing the preanesthesia checklist noted she received her anticoagulation that morning but did not notify the gastroenterologist. The patient had postprocedural bleeding.
Kiran Gupta, MD, MPH, and Raman Khanna, MD| August 21, 2016
A woman with a history of chronic obstructive pulmonary disease underwent hip surgery and experienced shortness of breath postoperatively. A chest radiograph showed a pneumothorax, but the radiologist was unable to locate the first call physician to page about this critical finding.
Julia Adler-Milstein, PhD| August 21, 2016
Because the hospital and the ambulatory clinic used separate electronic health records on different technology platforms, information on a new outpatient oxycodone prescription for a patient scheduled for total knee replacement was not available to the surgical team. The anesthesiologist placed an epidural catheter to administer morphine, and postoperatively the patient required naloxone and intubation.
Sonya P. Mehta, MD, MHS, and Karen B. Domino, MD, MPH| April 1, 2015
During laparoscopic subtotal colon resection for adenocarcinoma, a patient's bladder was accidentally lacerated and surgeons repaired it without difficulty. As nurses set up bladder irrigation equipment, no one noticed the bag of solution was dripping into the power supply of an anesthesiology monitor. Suddenly sparks and flames began shooting from the monitor, and the OR filled with black smoke. Fortunately, the fire was extinguished quickly and neither the patient nor any OR staff was injured.
by John G. DeVine, MD| March 1, 2015
A man with suspected renal cell carcinoma seen on CT in the right kidney was transferred to another hospital for surgical management. The imaging was not sent with him, but hospital records, which incorrectly documented the tumor as being on the left side—were. The second hospital did not obtain repeat imaging, and the surgeon did not see the original CT prior to removing the wrong kidney.
Krishna Moorthy, MD, MS| January 1, 2015
Following outpatient laparoscopic surgery to repair an inguinal hernia, a man with no significant past medical history had high levels of pain at the surgical site and was admitted to the hospital. With sustained pain on postoperative day 3, the patient developed tachycardia with abdominal distension and a low-grade fever. A CT scan revealed a bowel perforation, which required surgery and a lengthy ICU stay due to septicemia.
James Stotts, RN, MS, CNS, and Audrey Lyndon, PhD, RNC| May 1, 2014
In the preoperative area, a man scheduled for excision of a groin lipoma received regional anesthesia (right iliac block) and was taken to the operating room. There, without alerting anyone, the patient attempted to rise to use the restroom, but—because his leg was numb—fell and hit his head. He reported acute neck pain and was transferred to the local emergency department.
Kirsten Engel, MD| August 21, 2013
After changing the type of knee repair being done mid-procedure, a surgeon verbally informed the patient of drastically different discharge instructions in the post-anesthesia care unit but did not provide specific written instructions of the changed procedure or recovery plan to her or her husband.