Purpose or Case Report: A near-miss event is characterized by detection and correction of a gap in care before harm reaches the patient. After a near-miss event in which midgut volvulus (MGV) was identified on an ultrasound (US) performed for suspected hypertrophic pyloric stenosis (HPS), we implemented a new Vomiting Infant Protocol to capture cases of malrotation (MR)/MGV presenting with nonbilious emesis (NBE).
Methods & Materials: This quality project was implemented at an academic children’s hospital ED from April 2023 through September 2025. Before launch, radiologists provided US technologist training for evaluation of suspected MR/MGV to prepare for an US-first imaging apprach for infants with bilious emesis. To gain experience, US technologists added this protocol to exams performed for suspected HPS in infants with NBE. Early in the training period, a newborn with NBE was unexpectedly discovered to have MGV. To address this near-miss event, we formalized a Vomiting Infant Protocol (VIP) for infants aged 1 day to 4 months presenting to the ED with NBE. Infants presenting with bilious emesis were evaluated using the dedicated protocol for MR and MGV (MR/MGV Protocol). The new VIP included an initial evaluation of the superior mesenteric vessels and duodenum. If these images were normal or inconclusive, standard images of the pyloric channel (conventional HPS Protocol) were obtained. US exams were considered positive for MGV if either clockwise swirling of vessels/bowel (whirlpool sign) or SMA cut-off sign was seen; exams were considered positive for MR if there was abnormal SMV and SMA-aorta alignment or D3 course was anterior to the SMA.
Results: The new protocol was completed in 102 infants aged 1 day to 4 months presenting to our pediatric ED with reported or witnessed NBE. Three infants (ages 13 days, 15 days and 21 days) were identified to have MGV with positive whirlpool signs. All three infants underwent prompt surgical detorsion with preservation of bowel.
Conclusions: Responding to near-miss events—those that could have resulted in catastrophe but did not—is crucial to patient safety. Approximately 10–25% of infants with MR/MGV initially present with NBE, particularly if the obstruction is incomplete or intermittent. We used a near-miss event as an opportunity to add a simple step to a standardized US protocol for infants presenting with NBE. This swiftly implemented action item captured three infants with an unexpected diagnosis of MGV and facilitated prompt surgical detorsion.