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 involves a procedural sedation error in a 3-year-old patient who presented to the... Read More
This Spotlight Case highlights two cases of falls in older patients in nursing homes. The commentary discusses how risk factors... Read More
This case represents a known but generally preventable complication of calcium chloride infusion, eventually necessitating surgical... Read More
All WebM&M: Case Studies (16)
- Communication Improvement(9)
- Quality Improvement Strategies(7)
- Education and Training(6)
- Technologic Approaches(4)
- Error Reporting and Analysis(3)
- Computerized Decision Support(2)
- Computerized Provider Order Entry (CPOE)(2)
- Human Factors Engineering(2)
- Specialization of Care(2)
- Legal and Policy Approaches(1)
- Logistical Approaches(1)
An 18-month-old girl presented to the Emergency Department (ED) after being attacked by a dog and sustaining multiple penetrating injuries to her head and neck. After multiple unsuccessful attempts to establish intravenous access, an intraosseous (IO) line was placed in the patient’s proximal left tibia to facilitate administration of fluids, blood products, vasopressors, and antibiotics. In the operating room, peripheral intravenous (IV) access was eventually obtained after which intraoperative use of the IO line was restricted to a low-rate fluid infusion. An hour into the operation, the anesthesiologist found her left calf to be warm and tense, presumably due to fluid extravasation from the IO line. The IO line was removed, and the Orthopedic Surgery service was consulted intraoperatively due to concern for acute compartment syndrome. Signs of compartment syndrome eventually resolved without any surgical intervention. The commentary summarizes complications associated with IO lines, the importance of anticipating procedural complications, and methods to identify the signs and symptoms of acute compartment syndrome.
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.
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.