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 3
- Education and Training 3
- Error Reporting and Analysis 1
- Human Factors Engineering 2
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Specialization of Care 1
- Teamwork 1
Cindy S. Lee, MD, and Christopher P. Hess, MD, PhD; May 2016
An older man with a history of heavy smoking and chest pain underwent a chest CT in the emergency department that showed no evidence of an aortic dissection on the preliminary read. Although the patient followed up soon thereafter with a new primary care physician, it was not discovered until several months later that a suspicious lung nodule had been spotted on the initial CT.
Melvin P. Weinstein, MD; January 2008
Blood culture results on a man with chronic health problems revealed Corynebacterium spp. One month later, the patient became ill, and cultures again revealed Corynebacterium. The physician who received the result was unfamiliar with the patient, assumed that this finding was a contaminant, and took no action. Three weeks later, the patient was admitted and diagnosed with subacute bacterial endocarditis.
Michael Astion, MD, PhD ; December 2006
A man admitted to the hospital for elective surgery has blood drawn. Despite a policy for proper identification, the blood samples were all mislabeled with another patient's name. The error was discovered at the lab, and there was no harm to the patient.
D. John Doyle, MD, PhD ; July-August 2005
Following surgery, a woman receives morphine via a patient-controlled analgesia (PCA) pump. A few hours after arriving on the floor, she is found barely breathing.
- Spotlight Case
Douglas D. Brunette, MD; March 2005
The challenges of examining and imaging a hospitalized morbidly obese patient delay diagnosis, threatening the patient's life.