WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by readers. Spotlight Cases include interactive learning modules available for CME (Continuing Medical Education) and CPE (Continuing Pharmacy Education). Commentaries are written by patient safety experts and published monthly. You can contribute by submitting a case study anonymously.

Contents

• Neurological Red Flags: A Missed Stroke after Intermittent Episodes of Dizziness and Headache
  Jonathan A. Edlow, Professor of Emergency Medicine.
  Published online: December 18, 2024.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take Home Points
  • References
• Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis
  Jose A Castillo, Jr, Richard Price, Assistant Professor, and Kee D Kim, Professor.
  Published online: December 18, 2024.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk
  Marla Shauer, Assistant Clinical Professor, Diana Guzman Perez, Student, and Brenda Chagolla, Associate Chief Nursing Officer.
  Published online: December 18, 2024.
  • The Cases
  • The Commentary
  • Take Home Points
  • References
• Hypoxic Gas Supply from Cross-Connected Pipelines
  Christian Bohringer, Professor of Anesthesiology, Adam Guemidjian, Medical Student, and Garth Utter, Professor of Surgery.
  Published online: September 25, 2024.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Hypoxemia after Emergency Intubation
  Christian Bohringer, Professor of Anesthesiology and Hong Liu, Professor of Anesthesiology.
  Published online: December 18, 2024.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations
  David K. Barnes, Health Sciences Clinical Professor and Garth Utter, Professor.
  Published online: September 25, 2024.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head
  Ryan Martin, Associate Professor and Kiarash Shahlaie, Professor.
  Published online: October 30, 2024.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• A Tale of Two Falls
  Victoria Jackson, Assistant Clinical Professor and Anna Satake, Assistant Clinical Professor.
  Published online: October 30, 2024.
  • The Cases
  • The Commentary
  • Take-Home Points
  • References
• A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis
  Garth Utter, Professor.
  Published online: October 30, 2024.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• A Fatal Twist in Pseudohyperkalemia
  Justin L. Devera, Cardiovascular Medicine Fellow, David K. Barnes, Health Sciences Clinical Professor, and William R. Lewis, Professor.
  Published online: December 31, 2024.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Infection After Carpal Tunnel Surgery
  Robert M. Szabo, Distinguished Professor Emeritus of Orthopedics and Surgery.
  Published online: August 28, 2024.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy
  Brittany Newton, Emergency Medicine Senior Pharmacist and Roslyn Seitz, Health Sciences Assistant Clinical Professor.
  Published online: August 28, 2024.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Intraoperative Awareness during Rhinoplasty
  Christian Bohringer, Professor of Anesthesiology and Jaijeet Toor, Resident Physician.
  Published online: July 31, 2024.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency
  Jaenic Lee, Resident Physician, Joshua Fernelius, Resident Physician, and William Frick, Cardiology Fellow.
  Published online: December 31, 2024.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • Acknowledgements
  • References
• Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport
  Paul MacDowell, Medication Safety Officer and Eloh McGee, Resident Pharmacist.
  Published online: July 31, 2024.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery
  Christian Bohringer, Professor of Clinical Anesthesiology and Gustavo Chavez, Medical Resident.
  Published online: July 10, 2024.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns
  Scott Zakaluzny, Department of Surgery.
  Published online: July 10, 2024.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer
  Vijay Agusala, Cardiovascular Medicine Fellow, James Deen, Cardiovascular Medicine Fellow, and Saul Schaefer, Professor.
  Published online: May 29, 2024.
  • The Case
  • The Commentary
  • Take Home Points
  • References
• Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery
  Andrew P.J. Olson, Associate Professor of Medicine and Pediatrics.
  Published online: May 29, 2024.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement
  Sharmilee Vuyyuru, Clinical Nephrology Fellow and Nandakishor Kapa, Clinical Assistant Professor.
  Published online: May 29, 2024.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents?
  Ron Ordona, Health Sciences Assistant Clinical Professor and Deb Bakerjian, Clinical Professor.
  Published online: April 24, 2024.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Verbal Orders and Medication Overrides: A Dangerous Combination
  Catherine Mueller, Pharmacy Resident, Paul MacDowell, Medication Safety Officer, and James A. Bourgeois, Consulting Editor.
  Published online: April 24, 2024.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture
  David K. Barnes, Health Sciences Clinical Professor, Sahej Deep Singh Randhawa, Resident Physician, and Ellen P. Fitzpatrick, Associate Clinical Professor.
  Published online: April 24, 2024.
  • The Cases
  • The Commentary
  • Take-Home Points
  • References
• Misplaced Nasogastric Tube Resulting in Aspiration
  Anita Singh, Department of Internal Medicine and Cecilia Huang, Department of Internal Medicine.
  Published online: April 11, 2024.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences
  Karl Steinberg, President, National POLST Collaborative.
  Published online: March 27, 2024.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery
  Christian Bohringer, Professor of Anesthesiology, Manuel Fierro, Resident Physician, and Sandhya Venugopal, Associate Dean, Continuing Medical Education.
  Published online: April 24, 2024.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Do Not Miss Sepsis Needles in Viral Haystacks!
  Michelle Hamline, Assistant Professor and Ulfat Shaikh, Associate Editor, AHRQ’s Patient Safety Network (PSNet), Professor.
  Published online: March 27, 2024.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation
  James Bourgeois, Professor of Psychiatry and Glen Xiong, Clinical Professor of Psychiatry.
  Published online: March 27, 2024.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy
  Claudia López, Maternal Fetal Medicine Fellow and Véronique Taché, Professor.
  Published online: March 27, 2024.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures
  Caitlin Loseth, Surgical Critical Care Fellow.
  Published online: March 27, 2024.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
  Elizabeth Gould, ENT and Tracheostomy Advance Practice Specialist Nurse, Krystal Craddock, Reversible Obstructive Airway Disease (ROAD) Respiratory Therapist, Tyler LeTellier, Inpatient Tracheostomy Team – Respiratory Care, and Brooks T Kuhn, Assistant Professor of Clinical Medicine.
  Published online: May 29, 2024.
  • Learning Objectives
  • The Case
  • The Commentary
  • Conclusion
  • Take-Home Points
  • References
• Hindsight is 20/20: Thrombolytics for Alcohol Intoxication
  Eric Signoff, Health Sciences Clinical Associate Professor, Noelle Boctor, Health Sciences Clinical Assistant Professor, and David K. Barnes, Health Sciences Clinical Professor.
  Published online: April 10, 2024.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy
  Timothy Do, Medical Study and Fiona J. Scott, Assistant Professor.
  Published online: February 28, 2024.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Airway Obstruction during Anterior Cervical Spine Surgery
  Christian Bohringer, Professor of Anesthesiology and Linda Vo, Resident Physician.
  Published online: February 28, 2024.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Syringe Swap During Regional Block: A Case of Medication Error and Recovery
  Kimberly Beres, Chief Nurse Anesthetist and Maria Cristina Gutierrez, Associate Clinical Professor.
  Published online: January 31, 2024.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• A Laceration that Needed a Proper Exam, Not an X-Ray
  Jazmin A. Wander, Captain, USAF, MC and David K. Barnes, Health Sciences Clinical Professor.
  Published online: January 31, 2024.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Radiology Missed an Intracranial Bleed in a Lethargic Infant
  Jihey Yuk, Assistant Professor and Julia Magana, Associate Professor.
  Published online: January 4, 2024.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient
  Zack Chaffin, Health Sciences Assistant Clinical Professor.
  Published online: January 4, 2024.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!
  Berit Bagley, Advanced Practice Nurse Specialist, Charity L. Tan, Inpatient Glycemic Team Nurse Practitioner, and Deborah Plante, Director Inpatient Glycemic Team, Professor.
  Published online: November 30, 2023.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Medication Mix-Up Leads to Patient Death
  Luciano Sanchez, Resident Pharmacist and Patrick Romano, Co-Editor-in-Chief, AHRQ’s Patient Safety Network (PSNet), Professor.
  Published online: November 30, 2023.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon
  Christian Bohringer, Consulting Editor, AHRQ, Patient Safety Network (PSNet), Professor and Sharon Ashley, Professor.
  Published online: November 30, 2023.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• The Risks of a Malpositioned Gastrostomy Tube and Poor Communication
  Rachel A. Hight, Associate Professor, Associate Program Director, General Surgery Residency Program.
  Published online: November 29, 2023.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose
  Nidhi Patel Jain, Pharmacy Resident and David Dakwa, Assistant Chief, Acute Care Operations.
  Published online: October 31, 2023.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Delay in Malignancy Diagnosis Reflects Systemic Failures
  Hang Mieu, Resident Physician and Kristin Alexis Olson, Associate Dean of Curriculum and Medical Education, Professor and Vice Chair.
  Published online: October 31, 2023.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Walking Out of a Hospital After Attempted Suicide
  James Bourgeois, Consulting Editor, AHRQ’s Patient Safety Network (PSNet), Professor of Psychiatry and Glen Xiong, Clinical Professor of Psychiatry.
  Published online: September 27, 2023.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• A Missed Bowel Perforation - the Importance of Diagnostic Reasoning
  Leah Timbang, Resident Physician, Voltaire R. Sinigayan, Associate Clinical Professor, and Mithu Molla, Clinical Professor.
  Published online: September 27, 2023.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Delayed Evaluation of Abdominal Pain in an Elderly Patient
  Liliya Klimkiv, Resident Physician, Garth Utter, Consulting Editor, AHRQ’s Patient Safety Network (PSNet), Professor, and David K. Barnes, Consulting Editor, AHRQ’s Patient Safety Network (PSNet), Health Sciences Clinical Professor.
  Published online: September 27, 2023.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• A Double “Never Event”: Wrong Patient and Wrong Side
  Alyssa Bellini, Resident Physician and Edgardo S Salcedo, Professor, Interim Vice Chair of Education, Program Director, General Surgery Residency, Program Director, Surgical Education and Simulation Fellowship.
  Published online: September 27, 2023.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable
  Hana Camarillo, Clinical Pharmacist, Endocrinology.
  Published online: September 27, 2023.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Prolonged DKA in Pregnancy: A Case of Communication Breakdown
  Sarah Marshall, Health Sciences Clinical Professor and Nina M. Boe, Professor.
  Published online: August 30, 2023.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia
  Christian Bohringer, Consulting Editor, AHRQ, Patient Safety Network (PSNet), Professor of Anesthesiology and Ryan Osborne, Anesthesia Resident.
  Published online: August 30, 2023.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up
  Christian Bohringer, Consulting Editor, AHRQ, Patient Safety Network (PSNet), Professor of Anesthesiology, Emily Wei, Resident Physician, James Bourgeois, Consulting Editor, AHRQ, Patient Safety Network (PSNet), Professor of Psychiatry, and Glen Xiong, Associate Professor of Psychiatry.
  Published online: July 31, 2023.
  • The Case
  • The Commentary
  • Conclusion
  • Take-Home Points
  • References
• A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion
  Theresa Duong, Health Sciences Assistant Clinical Professor, Noelle Boctor, Consulting Editor, AHRQ, Patient Safety Network (PSNet), Associate Physician Diplomate, and James Bourgeois, Consulting Editor, AHRQ, Patient Safety Network (PSNet), Health Sciences Clinical Professor.
  Published online: July 31, 2023.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation
  Sean Flynn, Assistant Professor of Surgery and David K. Barnes, Health Science Clinical Professor.
  Published online: July 31, 2023.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Ventricular Wall Injury during a Diagnostic Cardiac Catheterization
  Tai Huu Pham, Professor of Clinical Anesthesiology and Surabhi Atreja, Clinical Professor.
  Published online: June 28, 2023.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Misconnection Leading to Arterial Thrombosis
  Christian Bohringer, Professor of Clinical Anesthesiology and Griffin Lee, Resident Physician.
  Published online: June 28, 2023.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Limb Loss after Vasopressor Use
  Mimmie Kwong, Assistant Professor.
  Published online: June 28, 2023.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department
  James A. Bourgeois, Consulting Editor, AHRQ, Patient Safety Network (PSNet), Glen Xiong, Clinical Professor, David K. Barnes, Consulting Editor, AHRQ, Patient Safety Network (PSNet), and Rupinder Sandhu, Nursing Director.
  Published online: June 14, 2023.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital
  Garima Agrawal and Diana Mai Nguyen.
  Published online: June 14, 2023.
  • The Case
  • The Commentary
  • Take-Home points
  • References
• Critical Echocardiogram Result Lost to Follow-up
  Noelle Boctor, Consulting Editor, AHRQ, Patient Safety Network (PSNet) and Mithu Molla, Clinical Professor.
  Published online: June 14, 2023.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture
  Elizabeth Gould, Kathleen M Carlsen, Assistant Clinical Professor PA and FNP Program, Jonathan Trask, Clinical Resource Nurse, and Brooks Thomas Kuhn, Assistant Professor of Clinical Medicine.
  Published online: June 28, 2023.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery
  Anna Curtin, Maternal Fetal Medicine Fellow and Nina Schloemerkemper, Professor.
  Published online: June 28, 2023.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes
  Barbara Resnick, Professor and Sonya Ziporkin Gershowitz Chair and Marie Boltz, Professor, Elouise Ross Eberly and Robert Eberly Endowed Chair, College of Nursing.
  Published online: April 26, 2023.
  • Learning Objectives
  • The Cases
  • The Commentary
  • Take Home Points
  • References
  • Acknowledgements
• The Danger of 10% Intravenous Calcium Chloride Extravasation
  Brent Luu, Associate Clinical Professor and Charleen Singh, Health Sciences Assistant Clinical Professor.
  Published online: April 26, 2023.
  • The Case
  • The Commentary
  • Take Home Points
  • References
• The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department
  Michael Leonardo Amashta, PGY3 Resident Physician and David K. Barnes, Health Sciences Clinical Professor.
  Published online: April 26, 2023.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take Home Points
  • References
• Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities
  James A. Bourgeois, Clinical Professor and Glen Xiong, Clinical Professor.
  Published online: March 29, 2023.
  • Learning Objectives
  • The Case
  • The Commentary
  • Conclusions
  • Take Home Points
  • References
• Procedure Complications – Who is Responsible for Follow up?
  Megan Chalupsky, Resident Physician, Huixia Wei, Associate Physician, and Emily Marquet.
  Published online: March 29, 2023.
  • The Case
  • The Commentary
  • Take Home Points
  • References
• Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue
  Samantha Jimenez, Clinical Fellow and Stephanie Crossen, Associate Professor.
  Published online: March 29, 2023.
  • The Case
  • The Commentary
  • Background
  • Take Home Points
  • References
• Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery
  Christian Bohringer, Professor of Clinical Anesthesiology.
  Published online: March 29, 2023.
  • The Case
  • The Commentary
  • Take-Home Points
  • References
• Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation
  Jonathan Trask, Clinical Resource Nurse, Kathleen M Carlsen, Assistant Clinical Professor PA and FNP Program, and Brooks Thomas Kuhn, Assistant Professor of Clinical Medicine.
  Published online: March 15, 2023.
  • Learning Objectives
  • The Case
  • The Commentary
  • Conclusion
  • Take-Home Points
  • References
• Duplicate Therapies in Retail Pharmacy
  Nisha Punatar, Associate Physician, Samson Lee, Population Health Pharmacist, and Mithu Molla, Health Sciences Clinical Professor.
  Published online: March 15, 2023.
  • The Cases
  • The Commentary
  • Conclusion
  • Take Home Points
  • References
• Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm
  Christian Bohringer, Professor of Clinical Anesthesiology.
  Published online: March 15, 2023.
  • The Case
  • The Commentary
  • Conclusion
  • Take Home Points
  • References
• Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists
  Lucy Shi, Associate Physician Diplomate and Erik Noren, Assistant Clinical Professor.
  Published online: March 15, 2023.
  • The Case
  • The Commentary
  • Take Home Points
  • References
• Medication Handling and Compounding Errors in the Operating Room
  Joy Chaudhry, Senior Clinical Pharmacist, Julie Chou, Courtney Manning, Resident Manager, Minji Kim, and David Dakwa, Assistant Chief.
  Published online: March 15, 2023.
  • The Case
  • The Commentary
  • Take Home Points
  • References
• Saved by ECMO
  Nicole A. Weiss, Assistant Professor.
  Published online: February 1, 2023.
  • The Case
  • The Commentary
  • Take Home Points
  • References
• Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts
  Craig Keenan, Professor of Medicine, Scott MacDonald, Chief Medical Information Officer, Dale Sapell, Clinical Pharmacist, and Ashley Takeshita.
  Published online: February 1, 2023.
  • Learning Objectives
  • The Case
  • The Commentary
  • Take Home Points
  • References
• Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure
  Elizabeth Partridge, Associate Clinical Professor, Daniel Dodson, Assistant Clinical Professor, Mary Reilly, and Stuart H. Cohen, Professor.
  Published online: February 1, 2023.
  • The Case
  • The Commentary
  • Take Home Points
  • References
• Hospital-Acquired Diabetic Ketoacidosis
  Dahlia Zuidema, Assistant Clinical Professor, Berit Bagley, Inpatient Glycemic Team, and Charity L Tan, Inpatient Glycemic Team.
  Published online: February 1, 2023.
  • The Cases
  • The Commentary
  • Background
  • Take Home Points
  • References
• Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma
  Claire E. Graves, Assistant Professor and Maggie A. Kuhn, Associate Professor.
  Published online: February 1, 2023.
  • Learning Objectives
  • The Cases
  • The Commentary
  • Take-Home Points
  • References
• Hospital-Acquired Diabetic Ketoacidosis
  Dahlia Zuidema, Berit Bagley, and Charity L Tan.
  Published online: February 1, 2023.
• Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis
  Narath Carlile, Clyde Lanford Smith, James H. Maguire, and Gordon D. Schiff.
  Published online: December 14, 2022.
• Don’t Bite Your Tongue
  Singh Naileshni S., Associate Professor.
  Published online: December 14, 2022.
• A framework for assessing reasoning about controversial end-of-life clinical decisions
  Mark Fedyk, Associate Professor, Nathan Fairman, Associate Clinical Professor, Patrick S. Romano, Professor, John MacMillan, Clinical Professor, and Monica Miller, Clinical Nurse.
  Published online: December 14, 2022.
• Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation
  Bohringer Christian and Luis A. Godoy.
  Published online: December 14, 2022.
• Mechanical Prosthetic Valve Thrombosis with Thromboembolism
  Nasim Hedayati and Richard White.
  Published online: November 16, 2022.
• Missed CANDOR Implementation Opportunities
  Leilani Schweitzer.
  Published online: November 16, 2022.
• The Unhappy Patient Leaves Against Medical Advice
  Amy A Nichols.
  Published online: October 27, 2022.
• False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy
  Brooks Thomas Kuhn, Assistant Professor of Clinical Medicine and Florence Chau-Etchepare, Assistant Professor of Clinical Medicine.
  Published online: October 27, 2022.
• Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan
  Carla S. Martin, Executive Director, Shannon K. Reese, Assistant Nurse Manager, and Margaret Brown-McManus, Unit Director.
  Published online: September 28, 2022.
• Delayed Diagnosis of Mesenteric Ischemia
  Anamaria Joyce Robles, Assistant Professor and Garth Utter.
  Published online: August 31, 2022.
• Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy
  Kevin J. Kelly, Emeritus Professor of Pediatrics, Allergy-Immunology.
  Published online: August 31, 2022.
• EMS Perils from Hospital Overcrowding
  Samantha Brown, John S. Rose, and David K. Barnes.
  Published online: August 31, 2022.
• Miscommunication During the Interhospital Transport of a Critically Ill Child
  Jennifer Rosenthal and Michelle Hamline.
  Published online: August 31, 2022.
• Challenges of Diabetes Management and Medication Reconciliation
  Samson Lee, Population Health Pharmacist and Mithu Molla, Health Sciences Clinical Professor.
  Published online: August 5, 2022.
• An Incomplete Anesthesia History Leads to Adverse Outcomes
  Christian Bohringer, Professor of Clinical Anesthesiology.
  Published online: July 8, 2022.
• Medication Safety Events Related to Diagnostic Imaging
  Luciano Sanchez, Hollie Porras, and Cathy R. Lammers.
  Published online: July 8, 2022.
• Preventable Transfer to the Hospital
  Garima Agrawal, Pouria Kashkouli, and Deb Bakerjian.
  Published online: July 8, 2022.
• Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures
  Kevin J. Keenan, Assistant Professor and Daniel K. Nishijima, Professor.
  Published online: July 8, 2022.
• Check Twice, Transport Once
  Alex DePew, James Rice, and Julie Chou.
  Published online: May 16, 2022.
• Intraosseous Line Extravasation in a Pediatric Trauma Patient
  David K. Barnes and Joseph A. Yoon.
  Published online: August 27, 2022.
• Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room
  Robert Scott Kriss, Health Sciences Associate Clinical Professor.
  Published online: April 27, 2022.
• Management of Cardiac Arrest in Unconventional Locations
  Garima Agrawal, Associate Physician Diplomate and Mithu Molla, Health Sciences Clinical Professor.
  Published online: May 16, 2022.
• A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care
  Katrina Pasao and Pouria Kashkouli.
  Published online: March 31, 2022.
• Delayed Diagnosis of Kidney Transplant Complications
  Nandakishor Kapa, Clinical Nephrology Fellow and José A. Morfín, Health Sciences Clinical Professor.
  Published online: February 23, 2022.
• A Loss of Trust and a Missed Diagnosis
  John Landefeld, Assistant Clinical Professor, Sara Teasdale, Assistant Clinical Professor, and Sharad Jain, Professor.
  Published online: February 23, 2022.
• Patient Safety Events Involving Opioid Dose Stacking
  Hollie Porras, Clinical Pharmacist, Pain Management and Cathleen Lammer, Professor.
  Published online: January 26, 2022.
• Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest
  Gary Raff and Brian Goudy.
  Published online: January 26, 2022.
• The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps
  Candice Sauder and Kleber Kara T.
  Published online: January 7, 2022.
• Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings
  Jane L. Erb, Sejal B. Shah, and Gordon D. Schiff.
  Published online: January 7, 2022.
• Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery
  Gary S. Leiserowitz and Hedriana Herman.
  Published online: November 30, 2021.
• Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care
  Hannah Spero, Health Sciences Assistant Clinical Professor, Angela E. Usher, Manager, Brian Howard, Medical Student, and Frederick J. Meyers, Professor.
  Published online: November 30, 2021.
• To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room
  Robin Aldwinckle, Clinical Professor and Edmund Florendo, Resident.
  Published online: October 27, 2021.
• xx
  Marissa G. Vadi, Health Sciences Associate Clinical Professor and Mathew R. Malkin, Health Sciences Associate Clinical Professor.
  Published online: October 27, 2021.
• Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome
  Linnea Lantz, Joseph Yoon, and David Barnes.
  Published online: September 29, 2021.
• Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations
  Florence Tan, Karnjit Johl, and Mariya Kotova.
  Published online: September 29, 2021.
• Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax
  Narath Carlile, Soheil El-Chemaly, and Gordon D. Schiff.
  Published online: July 25, 2021.
• Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected
  Minna Wieck, Assistant Professor of Surgery.
  Published online: August 25, 2021.
• Local Anesthesia-Induced Coma During Total Knee Arthroplasty
  Robin Aldwinckle, Clinical Professor.
  Published online: July 28, 2021.
• Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions
  Cynthia Li and Katrina Marquez.
  Published online: July 28, 2021.
• Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia
  Christian Bohringer, Professor of Clinical Anesthesiology.
  Published online: June 30, 2021.
• Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks
  David T. Martin and Diane PhD.
  Published online: June 30, 2021.
• Medication Errors in Retail Pharmacies: Wrong Patient, Wrong InstructionsThe Consequences of Miscommunication Regarding a Possible Artifact
  Kriti Gwal.
  Published online: June 30, 2021.
• The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers
  Katherine Glaser and Joy Vongspanich Dray.
  Published online: May 26, 2021.
• Hyponatremia Secondary to Home Parenteral Nutrition Error
  Kelly Haas and Andrew Lee.
  Published online: May 26, 2021.
• An Inadvertent Bolus of Norepinephrine
  Sarina A. Fazio, Emma J. Blackmon, Amy L. Doroy, Ai Nhat Vu, and Paul MacDowell.
  Published online: May 26, 2021.
• Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities
  Jeremiah Duby, Kendra Schomer, Victoria Oyewole, Delia Christian, and Sierra Young.
  Published online: May 26, 2021.
• A Postpartum Woman with an Erroneous SARS-CoV-2 Test
  Stephen A. Martin, Gordon D. Schiff, and Sanjat Kanjilal.
  Published online: April 28, 2021.
• A Sweet Case of Hidden Hydrogen Ions
  Deborah Plante and Andrea Falero.
  Published online: April 28, 2021.
• Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough
  Verna Gibbs.
  Published online: April 28, 2021.
• Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination
  Wesley Valdes and Garth Utter.
  Published online: March 31, 2021.
• The Impact of Communication on Medication Errors
  Jennifer Branch, Dakota Hiner, and Victoria Jackson.
  Published online: March 15, 2021.
• Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism
  David K. Barnes and William Ken McCallum.
  Published online: February 10, 2021.
• Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules
  Christian Bohringer, Professor of Clinical Anesthesiology.
  Published online: January 29, 2021.
• But See the Patient First
  Voltaire R Sinigayan.
  Published online: January 29, 2021.
• The NSTEMI Curbside Consultation
  Amparo C. Villablanca and Gordon X. Wong.
  Published online: July 29, 2020.
  • Case Objectives
  • The Case
  • The Commentary
  • Take-Home Points
  • References
  • Acknowledgement
• Misidentifying the Unidentified - John Doe and the EHR
  Christopher F. Janowak and Lauren M. Janowak.
  Published online: October 30, 2019.
  • The Case
  • The Commentary
  • Take Home/Teaching Points
  • References