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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: November 16, 2022
Nasim Hedayati, MD, and Richard White, MD | November 16, 2022

A 61-year-old women with a mechanical aortic valve on chronic warfarin therapy was referred to the emergency department (ED) for urgent computed tomography (CT) imaging of the right leg to rule out an arterial clot. CT imaging revealed two... Read More

Leilani Schweitzer | November 16, 2022

A 58-year-old man underwent a complex surgery to replace his aortic valve. The surgery required prolonged cardiopulmonary bypass time and cross-clamp time and there was a short delay in redosing the cardioplegic solution and the patient developed ... 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 (2)

Displaying 1 - 2 of 2 WebM&M Case Studies
Catherine Chia, MD and Mithu Molla, MD, MBA | May 27, 2020
A 55-year old man was admitted to the hospital for pneumonia requiring intravenous antibiotics. After three intravenous lines infiltrated, the attending physician on call gave a verbal order to have a percutaneous intravenous central venous catheter placed by interventional radiology the next morning. However, the nurse on duty incorrectly entered an order for a tunneled dialysis catheter, and the radiologist then inserted the wrong type of catheter. The commentary explores safety issues with verbal orders and interventional radiology procedures.
Neal L. Benowitz, MD| April 1, 2019
A woman who required oxygen at home via nasal cannula and used a continuous positive airway pressure (CPAP) machine at night was admitted for an exacerbation of chronic obstructive pulmonary disease without any signs of infection. During her hospital stay, she continued to require 5 liters of oxygen by nasal cannula. Although the patient had received smoking cessation education and no longer smoked regular cigarettes, she did continue to vape with an electronic cigarette (e-cigarette). Having not been told to avoid vaping in the hospital, the patient took a puff on her e-cigarette while she was receiving oxygen through her nasal cannula and sparked an explosion. She ripped off the nasal cannula, which had melted, and sustained burns to her face and hand, resulting in a prolonged hospitalization for burn care and extensive pain management.