U.S. Department of Health & Human Services
Cases & Commentaries
Discontinuities, Gaps, and Hand-Off Problems
Fatigue and Sleep Deprivation
Nonsurgical Procedural Complications
Psychological and Social Complications
Epidemiology of Errors and Adverse Events
Approach to Improving Safety
Quality Improvement Strategies
Legal and Policy Approaches
Error Reporting and Analysis
Human Factors Engineering
Specialization of Care
Culture of Safety
Education and Training
Allied Health Services
Health Care Providers
Health Care Executives and Administrators
Non-Health Care Professionals
Setting of Care
Submit a Case
Do you have a case that highlights medical errors that our editors should consider? All submissions are anonymous.
1 - 20
Don't Show Excerpt
Spotlight Cases Only
Sort by Date
Sort by Title
Sort by Author
Medical Devices in the "Wild"
with commentary by Ayse P. Gurses, PhD, and Peter Doyle, PhD
An elderly man was being prepared for discharge after being hospitalized for an exacerbation of congestive heart failure. His nurse failed to notice that the tubing of the patient's sequential compression devices (in place to prevent DVT) was caught on the bed wheel and had unlocked the bed when she raised it. When the patient attempted to get up later, the bed rolled out from under him and he fell, breaking his hip. One week after surgery, the patient experienced a cardiac arrest from a massive pulmonary embolism and died.
Ebola: Are We Ready?
with commentary by Jeffrey H. Barsuk, MD, MS, and Cynthia Barnard, MBA, MSJS
In a simulation exercise conducted in an institution that felt it was prepared for patients with actual or suspected Ebola, a man presented to the emergency department with symptoms of nausea, vomiting, and fever. He had recently returned to the US from Sierra Leone. The nurse initiated an isolation protocol and the critical care team all donned personal protective equipment. During transport, confusion about which elevators to use potentially exposed 30 staff members to Ebola. Additional issues occurred including breaching sterile technique while inserting a central line and confusion about the process to transport the patient's blood to the lab.
A Stroke of Error
with commentary by Kevin M. Barrett, MD, MSc
An elderly man admitted for a presumed hypertensive emergency and undiagnosed neurologic symptoms became unresponsive and was noted to have new right hand weakness 2 days into his hospitalization. After a "Code Stroke" was called, a neurologist evaluated him and administered tPA 100 minutes after the acute event. A few hours later, the patient developed further symptoms, and an emergent head CT demonstrated post-tPA intracerebral hemorrhage.
No BP During NIBP
with commentary by Matthias Görges, PhD, and J. Mark Ansermino, MBBCh, MSc
A man with atrial fibrillation underwent ablation in the catheterization laboratory under general endotracheal anesthesia. The patient was extremely stable during the 7-hour procedure with vital signs hardly changing over time. Inadvertently, the noninvasive blood pressure measurement stopped recording for 1 hour but went unnoticed. After the error was discovered, the case continued without any problems and the patient was discharged home the next day as planned.
Too Much, Too Fast
with commentary by Delphine Tuot, MDCM, MAS
A patient with ALS was hospitalized with presumed pneumonia and sepsis. Although he was treated with broad-spectrum antibiotics and fluid resuscitation, additional potassium was administered due to his potassium level remaining low. The patient went into cardiac arrest and resuscitation attempts were unsuccessful.
A Lot of Pain (Medications)
with commentary by Shoshana J. Herzig, MD, MPH
Hospitalized for foot amputation, a man with COPD and chronic pain on long-acting morphine experienced post-operative pain and severe muscle spasms. After being given hydromorphone, morphine, and diazepam, the patient became minimally responsive and a code blue was called.
Benefits vs. Risks of Intraosseous Vascular Access
with commentary by Raymond L. Fowler, MD, and Melanie J. Lippmann, MD
During a code blue, an intraosseous line was placed in the left tibia of an elderly woman after several unsuccessful attempts to obtain peripheral venous access. Following chest compressions and advanced cardiovascular life support protocol, spontaneous circulation returned and the patient was transferred to the intensive care unit. A few hours later, the left leg was dusky purple with sluggish distal pulses.
Liver Biopsy: Proceed With Caution
with commentary by Don C. Rockey, MD
Presenting with jaundice and epigastric pain, a woman with a history of multiple malignancies was admitted directly for an ultrasound-guided liver biopsy. After the procedure, the patient had low blood pressure and complained of new abdominal pain, which worsened over the next 2 hours. The bedside nurse soon found the patient unresponsive.
Pitfalls in Diagnosing Necrotizing Fasciitis
with commentary by Terence Goh, MBBS, and Lee Gan Goh, MBBS
Admitted with bruising from a fall and persistent pain on his left side, a patient was kept in the emergency department overnight due to crowding. After being reevaluated by the surgical service the next day, the patient was urgently taken to the operating room for probable necrotizing fasciitis and pyomysitis.
CVC Removal: A Procedure Like Any Other
with commentary by Michelle Feil, MSN, RN
Following removal of a central venous catheter placed during his admission for a prolonged course of intravenous antibiotics, a young man with a history of Behçet disease was discharged from the hospital. Shortly thereafter, he presented to the emergency department with acute onset shortness of breath and a "whistling sound" coming from his neck. Diagnosed with air embolism, he was admitted to the ICU.
May I Have Another?—Medication Error
with commentary by Michael Wolf, PhD, MPH
A man admitted to the hospital for his first seizure was found to have been taking up to 10 tablets of 10 mg zolpidem per night (an unsafe dose) to fall asleep and had recently run out. The instructions on the medication label had stated: "If ineffective, take another."
Wandering Off the Floors: Safety and Security Risks of Patient Wandering
with commentary by Thomas A. Smith, CHPA, CPP
Hospitalized for alcohol withdrawal, an elderly man was feeling "cooped up" by hospital day 6 and left the floor without informing any providers. An hour later upon return to his room, he complained of new arm pain. While off hospital grounds, the patient had fallen and broken his arm.
Discontinued Medications: Are They Really Discontinued?
with commentary by Celina Garza Mankey, MD, and Prathibha Varkey, MD, MPH, MBA
An elderly man on warfarin and aspirin for chronic atrial fibrillation and previous cerebrovascular accident presented to the emergency department with a severe headache. Found to have bilateral subdural hematomas and a supratherapeutic INR (4.9), he was admitted to the ICU. Even though the patient was discharged with his warfarin discontinued permanently, the outpatient pharmacy kept it on the active medication list and refilled his mail order prescription automatically, leading again to an elevated INR.
Raise the Bar
with commentary by James Stotts, RN, MS, CNS, and Audrey Lyndon, PhD, RNC
In the preoperative area, a man scheduled for excision of a groin lipoma received regional anesthesia (right iliac block) and was taken to the operating room. There, without alerting anyone, the patient attempted to rise to use the restroom, but—because his leg was numb—fell and hit his head. He reported acute neck pain and was transferred to the local emergency department.
Medication Reconciliation With a Twist (or Dare We Say, a Patch?)
with commentary by Janice L. Kwan, MD
An elderly woman with a history of dementia underwent surgical resection of new colon cancer, which relieved a bowel obstruction. She developed acute delirium postoperatively, and the team discovered they had neglected to capture her cholinesterase inhibitor patch (a medication for dementia) in the official medication reconciliation list.
CYP450 Drugs: Expect the Unexpected
with commentary by Charles John Gonzalez, MD
Scheduled for a hip replacement, a man with AIDS presented with sciatica. The spine surgeon administered a corticosteroid injection to control his symptoms. Soon after the patient experienced sweats, abdominal pain, weight gain, elevated blood pressure, insomnia, and anxiety. He was diagnosed with Cushing syndrome due to an adverse interaction between the HIV medication and the corticosteroid.
Relapse Secondary to Medication Access Issue
with commentary by Paul C. Walker, PharmD, and Jerod Nagel, PharmD
Following a hospitalization for
–associated diarrhea, a woman with HIV/AIDS and B-cell lymphoma was discharged with a prescription for a 14-day course of oral vancomycin solution. At her regular retail pharmacy, she was unable to obtain the medicine, and while awaiting coverage approval, she received no treatment. Her symptoms soon returned, prompting an emergency department visit where she was diagnosed with toxic megacolon.
A "Reflexive" Diagnosis in Primary Care
with commentary by John Betjemann, MD, and S. Andrew Josephson, MD
Despite new back pain and worsening symptoms of tingling, pain, and weakness bilaterally, in both hands and feet, a man recently diagnosed with peripheral neuropathy was not sent for further testing after repeated visits to a primary care clinic. By the time neurologists saw him, they diagnosed critical cervical cord compression, which placed the patient at risk for permanent paralysis.
Late Anemia Following Rh Disease in a Newborn
with commentary by Thomas B. Newman, MD, MPH, and M. Jeffrey Maisels, MB, BCh, DSc
Following delivery and successful phototherapy for hyperbilirubinemia, an infant developed anemia over the next few weeks. Found to have Rh hemolytic disease, the infant was admitted to the hospital for blood transfusion and close monitoring.
with commentary by William Ventres, MD, MA
A teenager presented to an urgent care clinic with new bumps and white spots near her tongue. Although she was diagnosed with herpetic gingivostomatitis, the after-visit summary incorrectly populated the diagnosis of "thrush" from the triage information, which was not updated with the correct diagnosis. The mistake on the printout caused confusion for the patient's mother and necessitated several follow-up communications to clear up.
Terms & Conditions
Produced for the
Agency for Healthcare Research and Quality
team of editors
University of California, San Francisco
with guidance from a prominent
. The AHRQ WebM&M site was designed and implemented by Silverchair.