WebM&M Cases & Commentaries
WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME. Commentaries are written by patient safety experts and published monthly. Contribute by Submitting a Case anonymously.
Narrow Results Clear All
- Communication Improvement 7
- Culture of Safety 1
- Education and Training 4
- Error Reporting and Analysis 1
- Human Factors Engineering 1
- Logistical Approaches 1
- Quality Improvement Strategies 5
- Specialization of Care 1
- Teamwork 2
- Diagnostic Errors 6
- Discontinuities, Gaps, and Hand-Off Problems 4
- Medical Complications 1
- Medication Safety 1
- Nonsurgical Procedural Complications 1
- Surgical Complications 1
- Spotlight Case
Elliott K. Main, MD; November 2016
After an emergency cesarean delivery, a woman had progressive tachycardia and persistent hypertension. A CT scan showed no evidence of pulmonary embolism, but repeat blood tests showed a dangerously low hemoglobin level and markedly elevated liver enzyme levels. She was taken back to the operating room and found to have postpartum hemorrhage.
Jennifer Malana, MSN, RN, and Audrey Lyndon, PhD, RN; October 2016
A pregnant woman was admitted for induction of labor for postterm dates. Prior to artificial rupture of membranes (AROM), the intern found a negative culture for group B strep in the hospital record but failed to note a positive culture in faxed records from an outside clinic. Another physician caught the error, ordered antibiotics, and delayed AROM to allow time for the medication to infuse.
- Spotlight Case
Mark W. Scerbo, PhD, and Alfred Z. Abuhamad, MD; January 2015
A woman who had an uncomplicated pregnancy and normal labor with no apparent signs of distress delivered a cyanotic, flaccid infant requiring extensive resuscitation. Although fetal heart rate tracings had shown signs of moderate-to-severe fetal distress for 90 minutes prior to delivery, clinicians did not notice the abnormalities on the remote centralized monitor, which displayed 16 windows, each for a different patient.
Thomas B. Newman, MD, MPH, and M. Jeffrey Maisels, MB, BCh, DSc; March 2014
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.
Baha Sibai, MD; June 2010
A woman with chronic hypertension developed undiagnosed preeclampsia during pregnancy with twins. At 38 weeks, she experienced respiratory and cardiac arrest. Although she eventually recovered, the infants were stillborn.
Mitch Rodriguez, MD, MBA; Rebecca Mannel, BS, IBCLC; Donna Frye, RN, MN; September 2008
After several pediatric visits, parents of a newborn with low output and weight loss contact a lactation consultant, who discovered that ankyloglossia (tongue-tie) was preventing the infant from receiving adequate intake from breastfeeding.
Louis P. Halamek, MD ; December 2005
A resident in the middle of delivering an infant turns away for a moment, during which the mother adjusts herself and the infant drops headfirst onto the floor.
Mark D. Pearlman, MD; Jeffrey S. Desmond, MD; May 2005
A woman who was 38 weeks pregnant came to the emergency department (ED) complaining of left leg pain. Ruled out for deep vein thrombosis, she was sent home, only to die the following morning.
Mark A. Rosen, MD; November 2003
Due to the delay in anesthesiology becoming available for an urgent C-section, an infant is delivered with profound neurologic abnormalities.
Bryony Dean Franklin, PhD; November 2003
An infant born with sluggish breathing is given Lanoxin instead of naloxone, and dies of digoxin toxicity.
Jackie Thomas, MD; Mary Hannah, MD; April 2003
Incorrect dating criteria in a woman late entering prenatal care nearly leads to induction of a pre-term infant.