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MARCH 2014New
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.
MARCH 2014New
After-Visit Confusion
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.
MARCH 2014NewSpotlight Case
Tough Call: Addressing Errors From Previous Providers
with commentary by William Martinez, MD, MS, and Gerald B. Hickson, MD
Hospitalized 3 times within 2 months presumably for sepsis, a woman with diabetes on metformin presented to the emergency department with the same set of symptoms as her previous admissions. After reviewing her records, the admitting team determined that the patient's presentation for this and earlier admissions was more consistent with acute lactic acidosis secondary to metformin than sepsis.
FEBRUARY 2014
An Easily Forgotten Tube
with commentary by Karen Ousey, PhD, RGN
A patient admitted for acute liver failure, acute renal failure, respiratory failure, and hepatic encephalopathy had a rectal tube placed to manage diarrhea. Two weeks into his hospitalization, dark red liquid stool was noted in the rectal tube, and the patient was found to have a large ulcerated area in the rectum, likely caused by the tube.
FEBRUARY 2014
Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients
with commentary by Jonathan P. Piccini, MD, MHS; L. Kristin Newby, MD, MHS; and Robert M. Califf, MD
A woman with coronary artery disease, diabetes, and hypertension was admitted for a myocardial infarction. Following percutaneous coronary intervention, the patient had several runs of non-sustained ventricular tachycardia (NSVT) and later experienced a cardiac arrest secondary to sustained VT.
FEBRUARY 2014Spotlight Case
Multifactorial Medication Mishap
with commentary by Annie Yang, PharmD, BCPS
Despite multiple checks by physician, pharmacist, and nurse during the medication ordering, dispensing, and administration processes, a patient received a 10-fold overdose of an opioid medication and a code blue was called.
DECEMBER 2013
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.
DECEMBER 2013
Check the Anesthesia Machine
with commentary by Daniel Saddawi-Konefka, MD, and Jeffrey B. Cooper, PhD
Prior to coronary artery bypass surgery, a man with morbid obesity, hypertension, diabetes, sleep apnea, claustrophobia, and 3-vessel coronary artery disease was given oxygen to achieve pre-oxygenation. Within a few minutes, the anesthesia team noted the patient was unresponsive with shallow breathing. Further investigation revealed the anesthesia machine was delivering 12% desflurane (a general anesthetic) instead of oxygen alone.
DECEMBER 2013Spotlight Case
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.
OCTOBER 2013
Finding Fault With the Default Alert
with commentary by Melissa Baysari, PhD
An epilepsy patient's discharge plan included phenytoin to be taken once daily. The prescribing physician was somewhat unfamiliar with the electronic medical record (EMR), didn't notice that the default frequency for phenytoin was "TID," and overrode the resultant computerized alert about the high dosage.
OCTOBER 2013
Are You Mrs. A? An Issue of Identification Over Telephone
with commentary by Jason S. Adelman, MD, MS
After a hospitalized patient died, the intern went to fill out the death certificate and notify the family. However, he picked up the chart of a different patient and mistakenly notified another patient's wife that her husband had died. He soon realized he'd notified the wrong family.
OCTOBER 2013Spotlight Case
It's Sarah, not Stephen!
with commentary by Urmimala Sarkar, MD, MPH
Although the mother of a child, born male who identified as and expressed externally as a girl, had alerted the clinic of the child's preferred name when making the appointment, the medical staff called for the patient in the waiting room using her legal (masculine) name.
SEPTEMBER 2013
A Picture Speaks 1000 Words
with commentary by Robin R. Hemphill, MD, MPH
Admitted to the hospital after hours, a patient with a history of type A aortic dissection had his CT scan read as "no acute changes." However, the CT scan had been compared to a text report of a previous scan, rather than the images. The patient died several hours later, and autopsy revealed the dissection had progressed and ruptured.
SEPTEMBER 2013
DRESSed for Failure
with commentary by Erika Abramson, MD, MS, and Rainu Kaushal, MD, MPH
After a new electronic health record was introduced without automatically transferring patients' allergy information to the corresponding fields, a woman was given an antibiotic she was allergic to, which resulted in her being admitted to the intensive care unit.
SEPTEMBER 2013Spotlight Case
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.
JULY/AUGUST 2013
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.
JULY/AUGUST 2013
Discharge Instructions in the PACU: Who Remembers?
with commentary by Kirsten Engel, MD
After changing the type of knee repair being done mid-procedure, a surgeon verbally informed the patient of drastically different discharge instructions in the post-anesthesia care unit but did not provide specific written instructions of the changed procedure or recovery plan to her or her husband.
JULY/AUGUST 2013Spotlight Case
Emergency Error
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.
MAY 2013
Don't Use That Port: Insert a PICC
with commentary by Roy Ilan, MD, MSc
A woman was emergently admitted for surgery for acute appendicitis. Although the patient had a chest port for breast cancer chemotherapy, the surgeon demanded that a peripherally inserted central catheter (PICC) be placed. The patient developed blood clots from the PICC, and surgery was cancelled. Significant complications, including perforation, peritonitis, and prolonged hospitalization, arose from managing the appendicitis conservatively.
MAY 2013
Polypharmacy
with commentary by B. Joseph Guglielmo, PharmD
On multiple oral medications and a depot injection (dispensed by a separate specialty pharmacy and administered at a clinic), a patient with schizophrenia was mistakenly given the depot injection kit by his local pharmacy and injected it himself.
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