| CLINICAL ETHICS | Back to Top | | Date | Title | Commentary by | | July 2003 |  Code Status Confusion | Bernard Lo, MD; James A. Tulsky, MD | | Excerpt: "A patient asks to be "DNR" because she misunderstood a vague discussion of resuscitation." |
| CRITICAL CARE | Back to Top | | Date | Title | Commentary by | | July 2004 | Novel Drug Misuse | Derek C. Angus, MD, MPH; Eric B. Milbrandt, MD, MPH | | Excerpt: "Following a motor vehicle collision, a patient is mistakenly given drotrecogin alfa (activated) for organ failure not due to sepsis." |
| EMERGENCY MED | Back to Top | | Date | Title | Commentary by | | February/March 2009 | All in the History | Christopher Fee, MD | | Excerpt: "Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism." | | March 2008 | Back Again | Jon D. Lurie, MD | | Excerpt: "A man went to the emergency department 3 times in 1 week for progressively worsening back pain. Providers assumed that the pain did not represent a serious illness; however, at the third visit, the patient was admitted and died of complications from an infection." | | Febuary 2006 | Lost in Transition | Christopher Beach, MD | | Excerpt: "A woman comes to the ED with mental status changes. Although numerous tests are run and she is admitted, a critical test result fails to reach the medicine team in time to save the patient's life." | | November 2005 | Reconciling Doses | Frank Federico, RPh | | Excerpt: "An elderly man on warfarin is admitted to the hospital with suspected meningitis. The admitting team bases his dose of warfarin on the paramedics' run-sheet but does not verify the dose. The patient winds up with a dangerous INR level, which causes a serious neurologic complication." | | June 2005 | Getting to the Root of the Matter | Scott A. Flanders, MD; Sanjay Saint, MD, MPH | | Excerpt: "Using a case of a dosing error, the authors describe the best practices in performing a root cause analysis." | | May 2005 | Diagnosing Diagnostic Mistakes | Robert McNutt, MD; Richard Abrams, MD; Scott Hasler, MD | | Excerpt: "Using past WebM&M cases, the authors discuss the challenges inherent in classifying diagnostic mistakes as medical errors. " | | April 2005 | Compare and Contrast | Kerry C. Cho, MD; Glenn M. Chertow, MD, MPH | | Excerpt: "A patient with presumed small bowel obstruction undergoes a contrast-enhanced CT scan. She develops contrast nephropathy requiring dialysis." | | January 2004 | Crushing Chest Pain: A Missed Opportunity | Mark Graber, MD | | Excerpt: "A patient with chest pain is incorrectly diagnosed as having had an MI. Although physicians eventually realize the patient had an aortic dissection, it is too late. The patient dies." |
| HOSPITAL MEDICINE | Back to Top | | Date | Title | Commentary by | | September 2006 | Triple Handoff | Arpana R. Vidyarthi, MD | | Excerpt: "An elderly man was admitted to the hospital for pacemaker placement. Although the postoperative chest film was normal, the patient later developed shortness of breath. Over the course of several nursing and physician shift changes and signouts, results of a follow-up stat x-ray are not properly obtained, delaying discovery of the patient's pneumothorax." | | March 2005 | Hidden Mystery | Douglas D. Brunette, MD | | Excerpt: "The challenges of examining and imaging a hospitalized morbidly obese patient delay diagnosis, threatening the patient's life." | | December 2004 | Discharge Fumbles | Alan Forster, MD, MSc | | Excerpt: "A patient arrives at the ED in acute kidney failure; another patient arrives at the ED profoundly hypoglycemic. Both mishaps were determined to stem from medication errors at the time of discharge." |
| MEDICINE | Back to Top | | Date | Title | Commentary by | | October 2009 | Difficult Encounters: A CMO and CNO Respond | Ernest J. Ring, MD; Jane E. Hirsch, RN, MS | | Excerpt: "Cardiology consultation on an elderly man admitted to the orthopedic service following a hip fracture reveals aortic stenosis. The cardiologist recommends against surgery, due to the risk of anesthesia. When the nurse reads these recommendations to the orthopedic resident, he calls her "stupid" and contacts the OR to schedule the surgery anyway. The Chief Medical Officer is called to intervene." | | May 2009 | Delirium or Dementia? | James L. Rudolph, MD, SM | | Excerpt: "An elderly woman hospitalized for pneumonia becomes disoriented during hospitalization. Even though the patient was never confused at baseline, doctors attribute it to "senile dementia" and place her in restraints." | | January 2009 | To Transfer or Not to Transfer | Jesse M. Pines, MD, MBA, MSCE | | Excerpt: "An elderly man, recently discharged from one hospital after having his automated internal cardioverter-defibrillator (AICD) replaced, is taken to another hospital when his AICD misfires multiple times. " | | October 2008 | Recurrent Hypoglycemia: A Care Transition Failure? | Ted Eytan, MD, MS, MPH | | Excerpt: "An elderly, non–English-speaking man with diabetes was admitted to the hospital twice in 8 days due to hypoglycemia. At discharge, the patient was instructed not to take any antidiabetic medications. In between hospitalizations, he saw his primary care physician, who restarted an antidiabetic medication." | | September 2008 | Empiric Steroids: the Good, the Bad, and the Ugly | Edward D. Harris, Jr., MD | | Excerpt: "For fear of exacerbating underlying disease processes, certain comorbidities should preclude the use of steroids. Three case examples illustrate appropriate indications and contraindications for using glucocorticoids." | | July 2008 | Dependence vs. Pain | Adam J. Gordon, MD, MPH | | Excerpt: "A man with a history of heroin use came to the hospital with abdominal pain, nausea, and vomiting. Admitted for dehydration and opiate withdrawal, he was given intravenous fluids, methadone, and morphine for abdominal pain. The patient complained of worsening pain overnight and was given more methadone. In the morning, the patient had more severe pain and tachycardia, and was found to have a perforated colon." | | May 2008 | Diagnosing HIV-It Doesn't Take a Brain Surgeon | Roger Chou, MD | | Excerpt: "Head imaging findings for a man admitted following new-onset headaches and a seizure revealed a brain mass. The patient was sent for craniotomy and brain biopsy, which revealed toxoplasmosis, prompting an HIV test that returned positive." | | April 2008 | Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad | Sumant Ranji, MD | | Excerpt: "A woman with symptoms of sinusitis was given 2 different courses of broad-spectrum antibiotics, neither of which improved her symptoms. Hospitalized for autoimmune hemolysis (presumably from the antibiotic), the patient suffered multiorgan failure and septic shock, and died." | | January 2008 | How Do Providers Recover from Errors? | Colin P. West, MD, PhD | | Excerpt: "An elderly man with COPD and end-stage congestive heart failure was admitted for increasing shortness of breath, due to a pleural effusion. A resident performed a thoracentesis on the wrong side, and the patient developed a pneumothorax and died. The resident disclosed the error but was devastated." | | December 2007 | Elopement | Debra Gerardi, RN, MPH, JD | | Excerpt: "An inpatient missing from his room is found several hours later outside the emergency department. Despite having arrived at the ED in a hospital gown with an inpatient ID bracelet, the patient is treated in the ED and discharged." | | July/August 2007 | Resuscitation Errors: A Shocking Problem | Benjamin S. Abella, MD, MPhil; Dana P. Edelson, MD | | Excerpt: "A code blue was called on a man admitted for chest pain, but the defibrillation pads placed on the patient were incompatible with the machine." | | May 2007 | Antiseizure Medication Disorder | Brian K. Alldredge, PharmD | | Excerpt: "An elderly patient with a seizure disorder (and recent admission for uncontrolled seizures) was admitted to the hospital to evaluate symptoms of lethargy, confusion, and decreased appetite. The team misattributed his mental status change to an infection but later discovered that the patient had phenytoin toxicity." | | December 2006 | Hidden Heparins: HIT Happens | Patrick F. Fogarty, MD | | Excerpt: "A hospitalized woman with multiple medical problems is diagnosed with heparin-induced thrombocytopenia (HIT) but is mistakenly exposed to heparin flushes during dialysis." | | November 2006 | Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality | Peter Lindenauer, MD, MSc | | Excerpt: "A woman with end stage renal disease and heart disease on anticoagulation receives a pneumonia vaccination that causes a large hematoma." | | August 2006 | Physical Diagnosis: A Lost Art? | George R. Thompson III, MD, and Abraham Verghese, MD | | Excerpt: "A man with paraplegia was admitted to the hospital, but the admitting physician, night float resident, and daytime team all "deferred" examination of the genital area. The patient was later discovered to have life-threatening necrotizing fasciitis of this area." | | September 2005 | Double Trouble | Jerry H. Gurwitz, MD | | Excerpt: "An elderly man with diabetes admitted to the hospital with hypoglycemia is switched from a combination medication (two pills in one) to a single drug. Two weeks later, he presents with mental status changes." | | July/August 2005 | Impatient Inpatient Dosing | Richard H. White, MD | | Excerpt: "An intern increases a patient's warfarin dosage nightly based on subtherapeutic INR levels drawn each morning; after several days, the patient develops potentially life-threatening bleeding. " | | October 2004 | Thin Air | David M. Gaba, MD | | Excerpt: "A dyspneic patient fails to improve after being placed on high-flow oxygen. The respiratory therapist soon discovers why: the patient is mistakenly receiving compressed room air." | | May 2004 | Too Tight Control | Haya R. Rubin, MD, PhD; Vera T. Fajtova, MD | | Excerpt: "To achieve tight glucose control, a hospitalized diabetes patient is placed on an insulin drip. Prior to minor surgery, he is made NPO and becomes severely hypoglycemic." | | March 2004 | Crossing the Line | Jeremy P. Feldman, MD; Michael K. Gould, MD, MS | | Excerpt: "A central line placed incorrectly causes a patient to suffer permanent neurologic damage." | | Febuary 2004 | Delay in Initiating Antibiotics Results in Fatal Error | Lisa M. Bellini, MD | | Excerpt: "Housestaff evaluate and admit a severely ill patient with lupus, suspect a viral syndrome, and do not initiate antibiotics. Despite discovery of the correct diagnosis in the morning by the attending, the patient dies." | | April 2003 | Another Fall | Sidney T. Bogardus, Jr., MD | | Excerpt: "Delirious and coagulopathic patient with subdural hematomas falls out of bed—twice!" |
| NURSING | Back to Top | | Date | Title | Commentary by | | August 2009 | Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care | Victoria Rich, PhD, RN | | Excerpt: "Admitted to the ICU for COPD exacerbation and atrial fibrillation, a patient who had stabilized is left unattended in the bathroom while the nurse on an understaffed unit attends to a more emergent patient. An assistant later finds the patient on the floor, unresponsive and cyanotic." | | July 2006 | Moving Pains | Hildy Schell, RN, MS, CCNS; Robert M. Wachter, MD | | Excerpt: "An elderly woman was transported to CT with no medical escort and an inadequate oxygen supply. She died later that day." |
| OB/GYN | Back to Top | | Date | Title | Commentary by | | October 2003 | The Other Side | Charles Vincent, PhD | | Excerpt: "Trusting his memory more than the chart, a surgeon directs a resident to remove the wrong side on a patient with unilateral vulvar cancer." |
| PEDIATRICS | Back to Top | | Date | Title | Commentary by | | April 2009 | Breakage of a PICC Line | Vesselin Dimov, MD | | Excerpt: "A premature infant had a PICC line placed for parenteral nutrition. During an attempt to remove it, the line broke. The infant had to be sent for surgical removal of the catheter and required an increased level of care, including ventilator support." | | November 2008 | Dangerous Shift | Emily S. Patterson, PhD | | Excerpt: "Due to lack of communication during shift change, an infant's transfer to a higher level of care is delayed. The infant develops respiratory distress, prompting a call to the rapid response team and transfer to the ICU." | | March 2007 | Failure to Report | Patrice L. Spath, BA, RHIT | | Excerpt: "An infant receives an overdose of the wrong antibiotic (cephazolin instead of ceftriaxone). The nurse spoke with the ED physician on duty but was informed that the medications were essentially equivalent and did not report the error." | | February 2007 | The "Customer" Is Always Right | Niraj L. Sehgal, MD, MPH | | Excerpt: "A parent brings her 18-month-old into the clinic with multiple complaints, including rash, diarrhea, and concern for fracture due to a fall. The child is sent home with a diagnosis of viral syndrome. Later, still concerned about her child's gait, the mother takes her to the ED, where an x-ray reveals a fractured tibia." | | June 2004 | The Wrong Shot: Error Disclosure | Thomas H. Gallagher, MD; Wendy Levinson, MD | | Excerpt: "A child is mistakenly vaccinated for hepatitis A, rather than B. Despite forthright disclosure and no evident harm to the child, the father becomes incredibly angry at the providers." | | September 2003 | Intubation Mishap | Matthew B. Weinger, MD; George T. Blike, MD | | Excerpt: "An infant acutely desaturates following an ED nurse's premature administration of a paralytic medication." | | May 2003 | Central Line Clot | Adrienne G. Randolph, MD, MSc | | Excerpt: "An infant codes due to pulmonary emboli after a central line flush." |
| RADIOLOGY | Back to Top | | Date | Title | Commentary by | | March 2006 | The Wet Read | Ronald L. Arenson, MD | | Excerpt: "A patient with metastatic cancer admitted for pain control develops acute shortness of breath. The overnight resident reads the CT as a large pulmonary embolism, but the next morning, the attending reads it differently." |
| SURG/ANESTHESIA | Back to Top | | Date | Title | Commentary by | | October 2007 | Do Not Disturb! | F. Daniel Duffy, MD; Christine K. Cassel, MD | | Excerpt: "Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call." | | September 2007 | Medication Reconciliation: Whose Job Is It? | Eric G. Poon, MD, MPH | | Excerpt: "Hospitalized for surgery, a woman with a history of seizures was given an overdose of the wrong medicine due to multiple errors, including an inaccurate preadmission medication list, failure to verify medication history, and uncoordinated information systems." | | June 2007 | Beeline to Spine | Gerald W. Smetana, MD | | Excerpt: "Based on preoperative discussions, a patient undergoing knee replacement expected to receive spinal anesthesia; however, general anesthesia was administered, and the records did not note or explain this change. The patient suffered an unusual complication." | | May 2006 | Right? Left? Neither! | Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD, MPP, MPH | | Excerpt: "A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers." | | April 2006 | Is the "Surgical Personality" a Threat to Patient Safety? | Charles L. Bosk, PhD | | Excerpt: "Because members of the OR team were reluctant to speak up to a senior surgeon with a reputation for yelling, a child undergoing surgery experiences a complication and has a delay in chemotherapy." | | January 2006 | An Ounce of Prevention | Nils Kucher, MD | | Excerpt: "Following reconstructive surgery to her hand, a woman suffers sudden cardiopulmonary arrest. After successful resuscitation, further review revealed that she had a pulmonary embolism and that she had received no venous thromboembolism prophylaxis. " | | December 2005 | Low on the Totem Pole | Robert M. Wachter, MD | | Excerpt: "A medical student notices that, prior to surgery, a urinary catheter is inserted into a child without sterile prep. Being new to the OR setting, he says nothing until a few days later on rounds when the patient shows signs of infection." | | September 2004 | Poor Prognosis | Elizabeth B. Lamont, MD, MS | | Excerpt: "Following hernia repair surgery, an elderly woman is incidentally found to have a mass in her neck. Expecting the worst, the treating physician recommends palliative care and withdrawal of mechanical ventilation, before biopsy results are in." | | November 2003 | The Missing Suction Tip | Eric J. Thomas, MD, MPH; Frederick A. Moore, MD | | Excerpt: "A scrub nurse cannot find a missing suction catheter tip, but the surgeon closes the patient. A post-operative x-ray reveals the tip in the patient's chest." | | June 2003 | Missed Appendicitis | James G. Adams, MD | | Excerpt: "Abdominal pain misdiagnosed in an ED patient leads to ruptured appendix, multiple complications, and prolonged hospitalization." | | Febuary 2003 | Unexplained Apnea under Anesthesia | Paul Barach, MD, MPH | | Excerpt: "A boy undergoing knee surgery stopped breathing after inadvertently being given a paralytic medication instead of an antibiotic." |
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