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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: December 14, 2022
Narath Carlile, MD, MPH, Clyde Lanford Smith, MD, MPH, DTM&H, James H. Maguire, MD, and Gordon D. Schiff, MD | December 14, 2022

This case describes a man in his 70s with a history of multiple myeloma and multiple healthcare encounters for diarrhea in the previous five years, which had always been attributed to viral or unknown causes, without any microbiologic or serologic... Read More

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Naileshni S. Singh, MD | December 14, 2022

A 63-year-old woman was admitted to a hospital for anterior cervical discectomy (levels C4-C7) and plating for cervical spinal stenosis under general anesthesia. The operation was uneventful and intraoperative neuromonitoring was used to help prevent... Read More

Mark Fedyk, PhD, Nathan Fairman, MD, MPH, Patrick S. Romano, MD, MPH, John MacMillan, MD, and Monica Miller, RN, MS, CCRN | December 14, 2022

A 65-year-old man with metastatic liver disease presented to the hospital with worsening abdominal pain after a partial hepatectomy and development of a large ventral hernia. Imaging studies revealed perforated diverticulitis. A goals-of-care... 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 (1)

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Displaying 1 - 1 of 1 WebM&M Case Studies
Stephen A. Martin, MD, EdM, Gordon D. Schiff, MD, and Sanjat Kanjilal, MD, MPH | April 28, 2021

A pregnant patient was admitted for scheduled Cesarean delivery, before being tested according to a universal inpatient screening protocol for SARS-CoV-2. During surgery, the patient developed a fever and required oxygen supplementation. Due to suspicion for COVID-19, a specimen obtained via nasopharyngeal swab was sent to a commercial laboratory for reverse transcriptase polymerase chain reaction (RT-PCR) testing. However, due to delays in receiving those results, another sample was tested two days later with a newly developed in-house test, and a third sample was sent to the state public health laboratory. The in-house test returned as positive for SARS-CoV-2. The patient was discharged in stable clinical condition but was advised to quarantine for 14 days. Two days after the patient’s discharge, the commercial and state lab tests were both reported as negative. A root-cause analysis subsequently determined that the positive test run on the in-house platform was due to cross-contamination from a neighboring positive sample. The commentary discusses the challenges associated with SARS-CoV-2 testing, the unprecedented burden faced by health systems, and downstream consequences of false positive tests.