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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 (89)

Published Date
PSNet Publication Date
1 - 20 of 89 WebM&M Case Studies
Cynthia Li, PharmD, and Katrina Marquez, PharmD| July 28, 2021

This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.

A 52-year-old man complaining of intermittent left shoulder pain for several years was diagnosed with a rotator cuff injury and underwent left shoulder surgery. The patient received a routine follow-up X-ray four months later. The radiologist interpreted the film as normal but noted a soft tissue density in the chest and advised a follow-up chest X-ray for further evaluation. Although the radiologist’s report was sent to the orthopedic surgeon’s office, the surgeon independently read and interpreted the same images and did not note the soft tissue density or order any follow-up studies. Several months later, the patient’s primary care provider ordered further evaluation and lung cancer was diagnosed. The commentary discusses how miscommunication contributes to delays in diagnosis and treatment and strategies to facilitate effective communication between radiologists and referring clinicians.  

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A 34-year-old morbidly obese man was placed under general anesthesia to treat a pilonidal abscess. Upon initial evaluation by an anesthesiologist, he was found to have a short thick neck, suggesting that endotracheal intubation might be difficult. A fellow anesthetist suggested use of video-laryngoscopy equipment, but the attending anesthesiologist rejected the suggestion. A first-year resident attempted to intubate the patient but failed. The attending anesthesiologist took over, but before intubation could be performed, the patient desaturated to 40-50%. A second attempt by the attending anesthesiologist at intubation with a glide scope also failed. The patient’s arterial saturation increased after administration of 100% oxygen by mask and he suffered no apparent neurological consequences. The commentary discusses best practices for managing high risk patients and appropriate use of advanced airway management devices.

Jeremiah Duby, PharmD, Kendra Schomer, PharmD, Victoria Oyewole, PharmD, Delia Christian, RN, BSN, CNRN, and Sierra Young, PharmD| May 26, 2021

A 65-year-old man with a history of type 2 diabetes mellitus, hypertension, and coronary artery disease was transferred from a Level III trauma center to a Level I trauma center with lower extremity paralysis after a ground level fall complicated by a 9-cm abdominal aortic aneurysm and cervical spinal cord injury. Post transfer, the patient was noted to have rapidly progressive ascending paralysis. Magnetic resonance imaging (MRI) revealed severe spinal stenosis involving C3-4 and post-traumatic cord edema/contusion involving C6-7. A continuous intravenous (IV) infusion of norepinephrine was initiated to maintain adequate spinal cord perfusion, with a target mean arterial pressure goal of greater than 85 mmHg. Unfortunately, norepinephrine was incorrectly programmed into the infusion pump for a weight-based dose of 0.5 mcg/kg/min rather than the ordered dose of 0.5 mcg/min, resulting in a dose that was 70 times greater than intended. The patient experienced bradycardia and cardiac arrest and subsequently died.

Deborah Plante, MD, and Andrea Gonzalez Falero, MD| April 28, 2021

A 24-year-old woman with type 1 diabetes presented to the emergency department with worsening abdominal pain, nausea, and vomiting. Her last dose of insulin was one day prior to presentation. She stopped taking insulin because she was not tolerating any oral intake. The admitting team managed her diabetes with subcutaneous insulin but thought the patient did not meet criteria for diabetic ketoacidosis (DKA), but after three inpatient days with persistent hyperglycemia, blurred vision, and altered mental status, a consulting endocrinologist diagnosed DKA. The patient was transferred to the intensive care unit (ICU) and an insulin drip was started, after which the patient’s metabolic derangements normalized and her symptoms resolved. The commentary discusses the importance of educating patients and providers on risk factors for DKA and symptoms in type 1 diabetics, the use of a stepwise approach to diagnosing acid-based disorders, clinical decision support tools to guide physiologic insulin replacement, and the role of closed-loop communication to decrease medical error.

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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Gary S. Leiserowitz, MD, MS and Herman Hedriana, MD| July 29, 2020

A 28-year-old woman arrived at the Emergency Department (ED) with back pain, bloody vaginal discharge, and reported she had had a positive home pregnancy test but had not received any prenatal care and was unsure of her expected due date. The ED intern evaluating the patient did not suspect active labor and the radiologist remotely reviewing the pelvic ultrasound mistakenly identified the fetal head as a “pelvic mass.” Four hours later, the consulting OB/GYN physician recognized that the patient was in her third trimester and in active labor. She was transferred to Labor and Delivery for labor management, which led to an emergency cesarean section. A neonatal seizure was observed, and brain MRI revealed a perinatal stroke. The Commentary discusses the types of diagnostic errors leading to missed diagnoses and the importance of appropriate supervision of physician trainees.

Julia Munsch, PharmD and Amy Doroy, PhD, RN | June 24, 2020
A 55-year old woman became unarousable with low oxygen saturation as a result of multiple intravenous benzodiazepine doses given overnight. The benzodiazepine was ordered following a seizure in the intensive care unit (ICU) and was not revised or discontinued upon transfer to the floor; several doses were given for different indications - anxiety and insomnia. This case illustrates the importance of medication reconciliation upon transition of care, careful implementation of medication orders in their entirety, assessment of patient response and consideration of whether an administered medication is working effectively, accurate and complete documentation and communication, and the impact of limited resources during night shift.
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Tanya Rinderknecht, MD and Garth Utter MD, MSc| April 29, 2020
A 52-year old women presented to the emergency department with a necrotizing soft tissue infection (necrotizing fasciitis) after undergoing cosmetic abdominoplasty (‘tummy tuck’) elsewhere. A lack of communication and disputes between the Emergency Medicine, Emergency General Surgery and Plastic Surgery teams about what service was responsible for the patient’s care led to delays in treatment. These delays allowed the infection to progress, ultimately requiring excision of a large area of skin and soft tissue.
Mikael Broman, MD, PhD| April 29, 2020
A 54-year old women with chronic obstructive pulmonary disease was admitted for chronic respiratory failure. Due to severe hypoxemia, she was intubated, mechanically ventilated and required extracorporeal membrane oxygenation (ECMO). During the hospitalization, she developed clotting problems, which necessitated transfer to the operating room to change one of the ECMO components. On the way back to the intensive care unit, a piece of equipment became snagged on the elevator door and the system alarmed. The perfusionist arrived 30-minutes later and realized that the ECMO machine was introducing room air to the patient’s circulation, leading to air embolism. The patient became severely hypotensive and bradycardic, and despite aggressive attempts at resuscitation, she died.
Two patients admitted for deceased donor renal transplant surgery experienced similar near miss errors involving 1000 ml normal saline bags with 160mg gentamicin intended as bladder irrigation but mistakenly found spiked or next to the patient’s intravenous (IV) line. Confusion about using this nephrotoxic drug intravenously could result in significant harm to patients undergoing renal transplant surgery.
Erika Cutler, PharmD, and Delani Gunawardena, MD | December 18, 2019
A 55-year-old man visited his oncologist for a follow-up appointment after completing chemotherapy and reported feeling well with his abdominal and bony pain well controlled with opioid therapy.  At the end of the visit, his oncologist reordered his pain medication and, due to a best practice alert, also prescribed naloxone but failed to provide any instruction on its use. Later that day, the patient took the naloxone along with his opioid pain medication and within a minute experienced severe abdominal and bony pain, requiring admission to the emergency department.
Stephanie Mueller, MD, MPH| February 1, 2019
To transfer a man with possible sepsis to a hospital with subspecialty and critical care, a physician was unaware of a formal protocol and called a colleague at the academic medical center. The colleague secured a bed, and the patient was sent over. However, neither clinical data nor the details of the patient's current condition were transmitted to the hospital's transfer center, and the receiving physician booked a general ward bed rather than an ICU bed. When the patient arrived, his mentation was altered and breathing was rapid. The nurse called the rapid response team, but the patient went into cardiac arrest.
Annie Yang, PharmD, BCPS| February 1, 2014
Despite multiple checks by physician, pharmacist, and nurse during the medication ordering, dispensing, and administration processes, a patient received a 10-fold overdose of an opioid medication and a code blue was called.
Daniel Saddawi-Konefka, MD, and Jeffrey B. Cooper, PhD| December 1, 2013
Prior to coronary artery bypass surgery, a man with morbid obesity, hypertension, diabetes, sleep apnea, claustrophobia, and 3-vessel coronary artery disease was given oxygen to achieve pre-oxygenation. Within a few minutes, the anesthesia team noted the patient was unresponsive with shallow breathing. Further investigation revealed the anesthesia machine was delivering 12% desflurane (a general anesthetic) instead of oxygen alone.
Melissa Baysari, PhD| October 1, 2013
An epilepsy patient's discharge plan included phenytoin to be taken once daily. The prescribing physician was somewhat unfamiliar with the electronic medical record (EMR), didn't notice that the default frequency for phenytoin was "TID," and overrode the resultant computerized alert about the high dosage.
Robin R. Hemphill, MD, MPH| September 1, 2013
Admitted to the hospital after hours, a patient with a history of type A aortic dissection had his CT scan read as "no acute changes." However, the CT scan had been compared to a text report of a previous scan, rather than the images. The patient died several hours later, and autopsy revealed the dissection had progressed and ruptured.
Robert L. Poole, PharmD; Tessa Dixon, PharmD| December 1, 2010
Following a vehicle collision, a man admitted to the hospital was given a twofold overdose of dexamethasone, due to confusion about administration instructions on a multidose vial.
Caprice C. Greenberg, MD, MPH| October 1, 2010
Following an appendectomy, an elderly man continued to have right lower quadrant pain. Reviewing the specimen removed during the surgery, the pathologist found no appendiceal tissue. The patient was emergently taken back to the OR, and the appendix was located and removed.