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.
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- Communication Improvement 3
- Error Reporting and Analysis 5
- Human Factors Engineering 1
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Teamwork 1
- Technologic Approaches 1
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Interruptions and distractions 1
- Medication Errors/Preventable Adverse Drug Events 3
- Surgical Complications 1
Reza Alaghehbandan, MD, MSc, and Stephen S. Raab, MD; March 2013
A woman with abdominal pain, bloating, and weight loss went to her primary physician, who ordered imaging and a biopsy. Lymph node pathology was reported as Castleman disease. A specialist felt the presentation and test results were atypical for this diagnosis. Further testing revealed adult-onset celiac disease.
- Spotlight Case
Richard H. White, MD ; July-August 2005
An intern increases a patient's warfarin dosage nightly based on subtherapeutic INR levels drawn each morning; after several days, the patient develops potentially life-threatening bleeding.
Robert L. Wears, MD, MS; September 2004
A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and winds up hanging the bag anyway.
- Spotlight Case
Eric J. Thomas, MD, MPH; Frederick A. Moore, MD; November 2003
A scrub nurse cannot find a missing suction catheter tip, but the surgeon closes the patient. A post-operative x-ray reveals the tip in the patient's chest.
Bryony Dean Franklin, PhD; November 2003
An infant born with sluggish breathing is given Lanoxin instead of naloxone, and dies of digoxin toxicity.