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.

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This Month's WebM&Ms

Update Date: March 29, 2023

Spotlight Case

CE/MOC

New

Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities.

James A. Bourgeois, OD, MD, and Glen Xiong, MD | March 29, 2023

An adult woman with a history of suicidal ideation was taking prescribed antidepressants, but later required admission to the hospital after overdosing on her prescribed medications. A consulting... Read More

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New

Procedure Complications – Who is Responsible for Follow up?

Megan Chalupsky, MD, Huixia Wei, MD, and Emily Marquet, MD | March 29, 2023

This patient with recently diagnosed adenocarcinoma of the esophagus underwent esophagoscopy with endoscopic ultrasound, which was complicated by thoracic esophageal perforation. The perforation was endoscopically closed during the... Read More

New

Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.

Christian Bohringer, MD | March 29, 2023

A 48-year-old obese man with a history of obstructive sleep apnea was placed under general anesthesia for corneal surgery. On completion of the operation, the patient was transferred to a motorized gurney to extubate him... Read More

New

Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.

Samantha Jimenez, MD, and Stephanie Crossen, MD | March 29, 2023

This case describes a 13-year-old girl who presented to several health care providers with typical symptoms, physical signs, and early laboratory findings suggestive of adrenal insufficiency (AI) yet the diagnosis was... Read More

Spotlight Case

CE/MOC

New

Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation

Jonathan Trask, RN, Kathleen M. Carlsen, PA, Brooks T. Kuhn, MD | March 15, 2023

A 72-year-old man was diagnosed with COVID-19 pneumonia and ileus, and admitted to a specialized COVID care unit. A nasogastric tube (NGT) was placed, supplemental oxygen was provided, and oral feedings were... Read More

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New

Medication Handling and Compounding Errors in the Operating Room.

Joy Chaudhry, PharmD, BCPS, BCCCP, Julie Chou BSN, RN, CNOR, Courtney Manning, PharmD, MBA, Minji Kim, RN, BSN, CNOR, and David Dakwa, PharmD, MBA, BCPS, BCSCP | March 15, 2023

This case focuses on immediate-use medication compounding in the operating room and how the process creates situations in which medication errors can occur. The commentary discusses strategies for safe perioperative compounding and the... 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.

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All WebM&M: Case Studies (596)

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Displaying 581 - 596 of 596 WebM&M Case Studies

The Dangerous Detour

Josh Gibson, MD; David H. Taylor, MD| June 1, 2003

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En route to x-ray, suicidal patient attempts to hang herself in washroom.

The Dropped Lung

John E. Heffner, MD | May 1, 2003

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A chest x-ray incorrectly read as pleural effusion, rather than lung collapse, leads to iatrogenic pneumothorax following thoracentesis.

Bloody BP Cuff

Atul K. Madan, MD | May 1, 2003

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A blood-soaked BP cuff used on one trauma patient is re-used on the next trauma patient, with no regard to universal precautions.

Ectopic or Not?

Vanessa M. Givens, MD; Gary H. Lipscomb, MD| May 1, 2003

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A woman is given methotrexate prematurely for suspected ectopic pregnancy and ultimately has salpingectomy.

Central Line Clot

Adrienne G. Randolph, MD, MSc | May 1, 2003

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An infant codes due to pulmonary emboli after a central line flush.

Suicidal Man With Gun

Robert I. Simon, MD| May 1, 2003

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Suicidal patient who admits having firearm refuses to remove gun from home for nearly 3 months.

Another Fall

Sidney T. Bogardus, Jr., MD| April 1, 2003

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Delirious and coagulopathic patient with subdural hematomas falls out of bedtwice!

Which End Is Which?

Andre R. Campbell, MD| April 1, 2003

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Laparoscopic colostomy completed in reverse induces total bowel obstruction.

Premature or Overdue?

Jackie Thomas, MD; Mary Hannah, MD| April 1, 2003

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Incorrect dating criteria in a woman late entering prenatal care nearly leads to induction of a pre-term infant.

Medication Overdose

Rainu Kaushal, MD, MPH| April 1, 2003

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A boy received an overdose of phenytoin due to ambiguous use of abbreviations.

The 2-Week Itch

Michael Cohen, RPh, MS, ScD (hon)| April 1, 2003

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Antipsychotic, rather than antihistamine, mistakenly dispensed to woman with bipolar disorder with new urticaria.

Patient Mix-Up

Kaveh G. Shojania, MD| February 1, 2003

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A man almost received a medication intended for another patient with the same last name in the same room.

Unexplained Apnea Under Anesthesia

Paul Barach, MD, MPH| February 1, 2003

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A boy undergoing knee surgery stopped breathing after inadvertently being given a paralytic medication instead of an antibiotic.

Procedural Mishap: Learning Curve?

Verna C. Gibbs, MD; Lucian L. Leape, MD | February 1, 2003

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A woman required emergency vascular surgery due to a complication during routine laparoscopic tubal ligation.

Flying Object Hits MRI

John Gosbee, MD, MS; Laura Lin Gosbee, MASc| February 1, 2003

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An infusion pump being used for routine sedation in a child undergoing a magnetic resonance imaging (MRI) scan flew across the room and hit the MRI magnet, narrowly missing the child.

When "Psychiatric" Symptoms Are Not

Richard J. Goldberg, MD, MS| February 1, 2003

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An elderly man with delusions and progressive neurological symptoms initially attributed to psychosis is found to have metastatic cancer.

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