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
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
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
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
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
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
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
All WebM&M: Case Studies (596)
- Communication Improvement(321)
- Quality Improvement Strategies(175)
- Education and Training(150)
- Technologic Approaches(128)
- Human Factors Engineering(118)
- Error Reporting and Analysis(75)
- Specialization of Care(48)
- Logistical Approaches(41)
- Computerized Provider Order Entry (CPOE)(40)
- Legal and Policy Approaches(35)
- Culture of Safety(34)
- Computerized Decision Support(31)
- Policies and Operations(14)
- Care Coordination(4)
- Transparency and Accountability(2)
- Medication Safety(188)
- Discontinuities, Gaps, and Hand-Off Problems(175)
- Diagnostic Errors(140)
- Surgical Complications(84)
- Medical Complications(66)
- Device-Related Complications(55)
- Nonsurgical Procedural Complications(42)
- Psychological and Social Complications(40)
- Identification Errors(32)
- Interruptions and distractions(23)
- Alert fatigue(12)
- Transfusion Complications(5)
- Failure to rescue(4)
- MRI safety(4)
- Inpatient suicide(3)
- Second victims(2)
- Drug shortages(1)
- Fatigue and Sleep Deprivation(1)
- Transitions of Care(1)
A 71-year-old frail, non-ambulatory woman presented to the emergency department with fever, sweating and dry cough. Her work-up included non-specific evidence of infection but two negative COVID-19 tests. No source of infection was identified, and she was discharged home after three days. During a video visit with her primary care provider the next day, the patient noted worsening symptoms as well as a skin breakdown on her “backside”; however, no rectal or genital exams were completed during her inpatient stay and the physician did not visualize the area during the video visit. The patient was readmitted to the hospital two days later in septic shock due to a necrotizing soft tissue infection related to a perirectal abscess. The commentary discusses the need for a broad differential diagnosis in seriously ill patients, the influence of diagnostic biases during a pandemic, and how to address perceived limitations in the ability to examine patients in the setting of virtual care.
A 93-year-old man on warfarin with chronic heart failure, atrial fibrillation, and a ventricular assist device (VAD) was admitted to the hospital upon referral from the VAD team due to an elevated internal normalized ratio (INR) of 13.4. During medication review, the hospital team found that his prescribed warfarin dose was 4 mg daily on Mondays and Fridays and 3 mg daily on all other days of the week; this prescription was filled with 1 mg tablets. However, his medication list also included an old prescription for 5 mg tablets. After discussions with the patient’s family, it was determined that the patient’s daughter had inadvertently given the patient three 5 mg tablets of warfarin (total daily dose 15 mg) for the past two days. This commentary discusses the importance of understanding patient safety risk, communication across transitions of care, and improving caregiver education and engagement to reduce medication errors.
A 56-year-old women with a history of persistent asthma presented to the emergency department (ED) with shortness of breath and chest tightness that was relieved with Albuterol. She was admitted to the hospital for acute asthma exacerbation. Given a recent history of mobility limitations and continued clinical decompensation, a computed tomography (CT) angiogram of the chest was obtained to rule out pulmonary embolism (PE). The radiologist summarized his initial impression by telephone to the primary team but the critical finding (“profound evidence of right heart strain") was not conveyed to the primary team. The written radiology impression was not reviewed, nor did the care team independently review the CT images. The team considered her to be low-risk and initiated therapy with a direct oral anticoagulant (DOAC). Later that day, the patient became hemodynamically unstable and was transferred to the intensive care unit (ICU). She developed signs of stroke and required ongoing resuscitation overnight before being transitioned to comfort care and died. This commentary discusses the importance of avoiding anchoring bias, effective communication between care team members, and reviewing all available test results to avoid diagnostic errors.
A 55-year-old man undergoing chemotherapy for acute myeloid leukemia was admitted to the hospital with a fever, neutropenia, and thrombocytopenia but physical examination did not reveal a focal site of infection. Blood and urine cultures were obtained, and he was started on IV antibiotics. His fever persisted and the cross-covering physician, following sign-out instructions from the primary team, requested repeat blood cultures but did not evaluate the patient in person. During rounds the next morning, the patient reported new oral pain (which had begun the previous day) and on physical exam was found to have mucositis. The associated commentary discusses the importance of in-person assessment in the hospital setting during cross-coverage and the value of structured, validated hand-off tools for communication among multidisciplinary teams.
A man with a history of previous airway operations was admitted for a rigid direct laryngoscopy. The consulting physician anesthesiologist prescribed a resident to administer ketamine to the patient as part of the general anesthesia protocol. The resident unintentionally located two vials of 100mg/mL ketamine (instead of the intended 10mg/mL vials that are used routinely) and erroneously administered 950mg of ketamine (instead of the intended 95mg). The dosing error resulted in delayed emergence from anesthesia and an unnecessary transfer to the intensive care unit for ventilation and monitoring, but was discharged home the following day. The commentary discusses the challenges of medication administration, the role of double-checking, and the importance of trainee supervision.
A 65-year-old man with metastatic cancer and past medical history of schizophrenia, developmental delay, and COPD was admitted to the hospital with a spinal fracture. He experienced postoperative complications and continued to require intermittent oxygen and BIPAP in the intensive care unit (ICU) to maintain oxygenation. Upon consultation with the palliative care team about goals of care, the patient with telephonic support of his long time caregiver, expressed his wish to go home and the palliative care team, discharge planner, and social services coordinated plans for transfer home. Although no timeline for the transfer had been established, the patient’s code status was changed to “Do Not Resuscitate” (DNR) with a plan for him to remain in the ICU for a few days to stabilize. Unfortunately, the patient was transferred out of the ICU after the palliative care team left for the weekend and his respiratory status deteriorated. The patient died in the hospital later that week; he was never able to go home as he had wished. The associated commentary describes how care inconsistent with patient goals and wishes is a form of preventable harm, discusses the need for clear communication between care team, and the importance of providers and healthcare team members serving as advocates for their vulnerable patients.
A 3-month-old male infant, born at 26 weeks’ gestation with a history of bowel resection and anastomosis due to necrotizing enterocolitis, was readmitted for abdominal distension and constipation. He was transferred to the pediatric intensive care unit (PICU) for management of severe sepsis and an urgent exploratory laparotomy was scheduled for suspected obstruction. The PICU team determined that the patient was stable for brief transport from the PICU to the operating room (OR). During intrahospital transport, the patient had two bradycardic episodes – the first self-resolved but the second necessitated chest compressions and intubation. The patient was rapidly moved to the OR where return of spontaneous circulation occurred within five minutes. The associated commentary describes the risks associated with intrahospital transport (particularly among pediatric patients) and critical processes that should be put in place to mitigate these risks via clear communication and structured decision-making among the intrahospital transport team.
After a breast mass was identified by a physician assistant during a routine visit, a 60-year-old woman received a diagnostic mammogram and ultrasound. The radiology assessment was challenging due to dense breast tissue and ultimately interpreted as “probably benign” findings. When the patient returned for follow-up 5 months later, the mass had increased in size and she was referred for a biopsy. Confusion regarding biopsy scheduling led to delays and, 7 months after initial presentation, the patient was diagnosed with invasive breast cancer involving the axillary nodes and spine. The commentary discusses the diagnostic challenges of potentially discordant findings between imaging and physical exams and the importance of structured inter-professional handoffs and closed-loop referrals in reducing diagnostic delays and associated harm.
A 60-year-old male presented to the emergency department (ED) with his partner after an episode of dizziness and syncope when exercising. An electrocardiogram demonstrated non-ST-elevation myocardial infarction abnormalities. A brain CT scan was ordered but the images were not assessed prior to initiation of anticoagulation treatment. While awaiting further testing, the patient’s heart rate slowed and a full-body CT scan demonstrated an intracranial hemorrhage. An emergent craniotomy was performed and the patient later died. The commentary discusses the influence of cognitive errors and the high-risk nature of anticoagulation contributing to this medical error, and the use of systematic interventions such as checklists and forcing functions to mitigate cognitive biases and prevent adverse outcomes.
After a failed induction at 36 weeks, a 26-year-old woman underwent cesarean delivery which was complicated by significant postpartum hemorrhage. The next day, the patient complained of severe perineal and abdominal pain, which the obstetric team attributed to prolonged pushing during labor. The team was primarily concerned about hypotension, which was thought to be due to hypovolemia from peri-operative blood loss. After several hours, the patient was transferred to the medical intensive care unit (ICU) with persistent hypotension and severe abdominal and perineal pain. She underwent surgery for suspected necrotizing fasciitis, but necrosis was not found. The patient returned to the surgical ICU but deteriorated; she returned to the operating room, where she was found to have necrotizing soft tissue infection, including in the flanks, labia, and uterus. She underwent extensive surgery followed by a lengthy hospital stay. The accompanying commentary discusses the contribution of knowledge deficits and cognitive biases to diagnostic errors and the importance of structured communications between professionals.
A 14-year-old girl with type 1 diabetes (T1D) was admitted to the hospital after two weeks of heavy menstrual bleeding as well as blurred vision, headache and left arm numbness. MRI revealed an acute right middle cerebral artery (MCA) infarct. Further evaluation led to a diagnosis of antiphospholipid syndrome. The patient was persistently hyperglycemic despite glycemic management using her home insulin pump and continuous glucose monitor. Over the course of her hospitalization, her upper extremity symptoms worsened, and she developed upper extremity, chest, and facial paresthesia. Imaging studies revealed new right MCA territory infarcts as well as splenic and bilateral infarcts. The case describes how suboptimal inpatient management of diabetes technology contributed to persistent hyperglycemia in the setting of an acute infarction. The commentary discusses best practices for optimizing patient safety when managing hospitalized patients on home insulin pumps.
A 58-year-old female receiving treatment for transformed lymphoma was admitted to the intensive care unit (ICU) with E. coli bacteremia and colitis secondary to neutropenia, and ongoing hiccups lasting more than 48 hours. She was prescribed thioridazine 10 mg twice daily for the hiccups and received four doses without resolution; the dose was then increased to 15 mg and again to 25 mg without resolution. When she was transferred back to the inpatient floor, the pharmacist, in reviewing her records and speaking with the resident physician, thioridazine (brand name Mellaril) had been prescribed when chlorpromazine (brand name Thorazine) had been intended. The commentary discusses the use of computerized physician order entry (CPOE) to reduce prescribing errors in inpatient settings and the importance of having a pharmacist on the patient care team to avoid prescribing errors involving less commonly prescribed medications.
A 73-year-old female underwent a craniotomy and aneurysm clipping to resolve a subarachnoid hemorrhage due to a ruptured aneurysm. The neurosurgery resident confirmed the presence of neuromonitoring with the Operating Room (OR) front desk but the neuromonitoring technician never arrived and the surgeon – who arrived after the pre-op huddle – decided to proceed with the procedure in their absence. Although no problems were identified during surgery, the patient emerged from anesthesia with left-sided paralysis, and post-op imaging showed evidence of a new stroke. The commentary discusses the importance of huddles, ensuring closed-loop communication involving residents, and balancing benefits and risks during emergent surgical care.
A 44-year old man with hypertension and diabetes was admitted with an open wound on the ball of his right foot that could be probed to the bone and evidence of diabetic ketoacidosis. Over the course of the hospitalization, he had ongoing hypokalemia, low magnesium levels, an electrocardiogram showing a prolonged QT interval, ultimately leading to cardiac arrest due to torsades de pointes (an unusual form of ventricular tachycardia that can be fatal if left untreated). The commentary discusses the use of protocol-based management of chronic medical conditions, the inclusion of interprofessional care teams to coordinate management, and the importance of inter-team communication to identify issues and prevent poor outcomes.
This case involves a 65-year-old woman with ongoing nausea and vomiting after an uncomplicated hernia repair who was mistakenly prescribed topiramate (brand name Topamax, an anticonvulsant and nerve pain medication) instead of trimethobenzamide (brand name Tigan, an antiemetic) by the outpatient pharmacy. The commentary uses the Swiss Cheese Model to discuss the safety challenges of “look-alike, sound-alike” (LASA) medications, the importance of phyiscians employing “soft” skills during medication dispensing, and how medication administration errors can occur in outpatient pharmacy settings, despite multiple opportunities for cross-verification.
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.
A 56-year-old female received a digital tourniquet around the base of her left big toe during an ablation and excision of a deformed in-grown toenail. After the procedure, a dressing was applied and the patient was discharged 4 hours later. During the follow-up visit two-days later, the dressing was removed and revealed that the tourniquet was still in place and constricting the toe. The toe became necrotic and developed gangrene, and was amputated. The commentary discusses the safe use of digital tourniquets, the importance of including tourniquets in the surgical count process, and ensuring tourniquets are removed in a timely manner.
A 69-year-old man with cognitive impairment and marginal housing was admitted to the hospital for exacerbation of chronic obstructive pulmonary disease (COPD). After a four-day admission, the physician arranged for discharge and transport to residential care home and arranged for Meds-to-Beds (M2B), a service that collaborates with a local commercial pharmacy to deliver discharge medications to the bedside prior to the patient leaving the hospital. The medication pick-up was delayed for several hours and there were miscommunications among the pharmacy, social worker, and physician. Ultimately, the patient was discharged without his medications and was readmitted five hours later with dyspnea and hypoxia. The commentary suggests that 7- versus 30-day readmission rates may be more reflective of hospital readmission mitigation efforts and discusses the value of Meds-to-Beds (M2B) programs in improving adherence to medication regimens during transitions of care
A 52-year-old woman with a known history of coronary artery disease and ischemic cardiomyopathy was admitted for presumed community-acquired pneumonia. The inpatient medicine team obtained a “curbside” cardiology consultation which concluded that the worsening left ventricular systolic functioning was in the setting of acute pulmonary edema. Two months post-discharge, a nuclear stress test was suggestive of infarction and a subsequent catheterization showed a 100% occlusion. The commentary discusses cardiovascular-related diagnostic errors affecting women and the advantages, pitfalls and best practices for curbside consultations in acute care settings.
A patient was mistakenly administered intravenous fentanyl which was leftover from a previous patient and not immediately wasted. Experts recommend the best practice for the safe disposal, or “waste”, of medications in the surgical setting is to either waste any leftover product immediately after administration or to fully document all waste at the end of the case.This commentary discusses the policies and procedures addressing wasting of medication by anesthesiologists, approaches to reduce medication administration errors, and the importance identifying process gaps that could lead to potential diversion.