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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
This case describes the failure to identify a brewing abdominal process, which over the span of hours led to fulminant sepsis with... Read More
This case highlights two “never events” involving the same patient. A first-year orthopedic surgery resident was consulted to aspirate fluid from... Read More
A 42-year-old man with a history of posttraumatic stress disorder (PTSD), alcohol use disorder and anxiety disorder, was seen in the emergency... Read More
This case describes an older adult patient with generalized abdominal pain who was eventually diagnosed with inoperable bowel necrosis.... Read More
A 14-year-old girl was admitted to the hospital with a new diagnosis of type 1 diabetes mellitus without ketoacidosis. Before... Read More
All WebM&M: Case Studies (1)
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.
