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SNFs: Opening the Black Box
with commentary by Joseph G. Ouslander, MD, and Alice Bonner, PhD, GNP
Following a lengthy hospitalization, an elderly woman was admitted to a skilled nursing facility for further care, where staff expressed concern about the complexity of the patient's illness. A few days later, the patient developed a fever and shortness of breath, prompting readmission to the acute hospital.
New Oral Anticoagulants
with commentary by Margaret C. Fang, MD, MPH
Two days after knee replacement surgery, a woman with a history of deep venous thrombosis receiving pain control via epidural catheter was restarted on her outpatient dose of rivaroxaban (a newer oral anticoagulant). Although the pain service fellow scanned the medication list for traditional anticoagulants, he did not notice the patient was taking rivaroxaban before removing the epidural catheter, placing the patient at very high risk for bleeding.
The Pains of Chronic Opioid Usage
with commentary by Laxmaiah Manchikanti, MD, and Joshua A. Hirsch, MD
Hospitalized for pneumonia and asthma, a man with chronic pain was found to be using pain medications not prescribed to him. During his hospitalization, the pain service was consulted and changed his medications to better control the pain. Five days after discharge, the patient died, presumably from an unintentional overdose of his old and new prescriptions.
Anesthesia: A Weighty Issue
with commentary by Ashish C. Sinha, MD, PhD
Following general anesthesia for hip repair surgery, an elderly woman with a history of hypertension and obesity developed hypercarbic respiratory failure and was reintubated in the recovery unit. Providers felt the patient had undiagnosed obstructive sleep apnea and questioned whether obese patients undergoing anesthesia should receive formal preoperative screening for it.
with commentary by Nicholas Symons, MBChB, MSc
An elderly woman with severe abdominal pain was admitted for an emergency laparotomy for presumed small bowel obstruction. Shortly after induction of anesthesia, her heart stopped. She was resuscitated and transferred to the intensive care unit, where she died the next morning. The review committee felt this case represented a diagnostic error, which led to unnecessary surgery and a preventable death.
From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case
with commentary by David E. Newman-Toker, MD, PhD
Admitted to the hospital with headache and word-finding difficulties, a man was given a preliminary diagnosis of vasculitis. Although serial imaging studies seemed to indicate progression of his brain lesions, these were not biopsied and discovered to be glioblastoma multiforme until 4 months later. The delay in diagnosis contributed to his rapid clinical decline.
Total Parenteral Nutrition, Multifarious Errors
with commentary by Joseph I. Boullata, PharmD, RPh, BCNSP
A 3-year-old boy hospitalized with anemia who was on chronic total parenteral nutrition was given an admixture with a level of sodium 10-fold higher than intended. Despite numerous warnings and checks along the way, the error still reached the patient.
with commentary by Reza Alaghehbandan, MD, MSc, and Stephen S. Raab, MD
A woman with abdominal pain, bloating, and weight loss went to her primary physician, who ordered imaging and a biopsy. Lymph node pathology was reported as Castleman disease. A specialist felt the presentation and test results were atypical for this diagnosis. Further testing revealed adult-onset celiac disease.
The Unfamiliar Catheter
with commentary by Sonia C. Swayze, RN, MA, and Angela James, RN, BSN
While drawing labs on a woman admitted after a lung transplant, a nurse failed to clamp the patient's large-bore central line, allowing air to enter the catheter. The patient suffered a cerebral air embolism and was transferred to the ICU for several days.
CVC Placement: Speak Now or Do Not Use the Line
with commentary by Mark Ault, MD, and Bradley Rosen, MD, MBA
A woman found unresponsive at home presented to the ED via ambulance. The cardiology team used the central line placed during resuscitation to deliver medications and fluids during pacemaker insertion. Hours later, a chest radiograph showed whiteout of the right lung, and clinicians realized that the tip of the line was actually within the lung.
Death by PCA
with commentary by Rodney W. Hicks, PhD, RN, FNP
After delivering a healthy infant via Caesarean section, a young woman was to receive morphine via PCA pump. A mix-up in programming the concentration of medication delivered by the pump led to a fatal outcome.
Preventing PICC Complications: Whose Line Is It?
with commentary by Nancy Moureau, BSN, RN, CRNI, CPUI, VA-BC
A woman undergoing treatment for myasthenia gravis via PICC developed extensive catheter-related thrombosis, bacteremia, and sepsis, and ultimately died. Although the PICC line was placed at one facility, the patient was receiving treatment at another, raising questions about who had responsibility for the line.
A Real Heartache
with commentary by Steven K. Polevoi, MD
Following an emergency department (ED) evaluation for chest pain, a patient was discharged with a presumptive diagnosis of gastroesophageal reflux disease. Two days later, he returned to the ED in severe distress, now with an acute myocardial infarction and a large pericardial effusion.
The Lung Nodule That Refused To Grow
with commentary by Alex A. Balekian, MD, MSHS, and Michael K. Gould, MD, MS
At his first visit with a new physician, a man with a "spot" on his lung reported being followed with CT scans every 6–12 months for 8 years. In total, the patient had more than 20 CT scans.
with commentary by Jeffrey M. Rohde, MD, and Scott A. Flanders, MD
A 32-year-old man went to the emergency department with fever and pleuritic chest pain. Following an extensive work-up, he was discharged with "fever, pleural effusion, and chest wall pain", but no clear diagnosis. He returned to the ED 3 days later with worsening pain, continued fever, a new cough, and dyspnea. The patient was started on antibiotics and admitted for pneumonia with effusion.
with commentary by Manish S. Patel, MD, and Jeffrey L. Carson, MD
At a skilled nursing facility, an elderly woman with myelodysplastic syndrome was found to be mildly anemic, and her oncologist arranged for her to be sent to the hospital and transfused with 2 units of blood. Less than 1 hour after the second unit of blood finished transfusing, the patient rapidly worsened and had a respiratory arrest.
CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure
with commentary by Catherine Liu, MD
A teenage athlete noticed what he thought was an insect bite on his buttock, but only mentioned it to his mother a few days later, when it was much worse. Four days after his pediatrician prescribed antibiotics for CA-MRSA, the boy wound up hospitalized with complications from CA-MRSA, including acute renal failure, respiratory failure, and osteomyelitis of the femur head requiring total hip replacement.
Peripheral IV in Too Long
with commentary by Chi-Tai Fang, MD, PhD
Admitted with a congestive heart failure exacerbation, an elderly man acquired an infection around his peripheral IV site, accompanied by fever, chills, and back pain. Likely secondary to the infected peripheral IV catheter, the patient had developed methicillin-resistant
bacteremia and an epidural abscess.
Wrong Turn through Colon: Misplaced PEG
with commentary by Rachel Sorokin, MD, and Mitchell Conn, MD, MBA
Admitted for treatment of congestive heart failure, an elderly man with a percutaneously placed gastric feeding tube began to have liters of watery stool daily. A tube check revealed that the tip of the feeding tube was in the colon and not the stomach.
A Painful Dilemma
with commentary by Sara N. Davison, MD, MHSc
A woman with end-stage renal disease, who often skipped dialysis sessions, was admitted to the hospital with fever and given intravenous opiates for pain. Because her permanent arteriovenous graft was clotted, she had been receiving dialysis via a temporary femoral catheter, increasing her risk for infection. Blood cultures grew yeast; the patient was diagnosed with fungal endocarditis, likely caused by injections of opiates through her catheter.
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