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
Approach to Improving Safety
Standard Deviations
- Spotlight Case
James E. Sabin, MD; December 2009
A man with a history of IV drug use is admitted to the hospital and found to have an epidural abscess with surrounding osteomyelitis. Although the treatment plan required weeks of IV antibiotics, the patient (who fought with the nursing staff and threatened to leave against medical advice [AMA]) was discharged after 2 weeks on oral antibiotics. His condition worsened, and he returned 3 weeks later, but he ultimately left AMA and was lost to follow-up.
Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality
- Spotlight Case
Peter Lindenauer, MD, MSc; November 2006
A woman with end stage renal disease and heart disease on anticoagulation receives a pneumonia vaccination that causes a large hematoma.
Language Barrier
Glenn Flores, MD; April 2006
With no one to interpret for them and pharmacy instructions printed only in English, non–English-speaking parents give their child a 12.5-fold overdose of a medication.
Liposuction Gone Awry
James A. Yates, MD; March 2006
A man undergoes plastic surgery at an outpatient center and winds up with a complication requiring prolonged stay in the ICU.
Collegiality vs. Competence
Todd Sagin, MD, JD; March 2006
Despite formal investigation of complications in past cases, a senior surgeon is still allowed to operate on a patient, with disastrous results.
Carpe Diem (Seize the Day)
Allan Krumholz, MD; December 2004
At a new patient visit, a man with seizure disorder requests a 'handicapped' license plate due to difficulty walking long distances. To his surprise, the physician explains that he needs to report his seizures to the DMV.
Undiagnosed Vaginal Bleeding
Jeanne Mandelblatt, MD, MPH; February 2004
A physician who does not accept Medicaid turns away a woman needing evaluation for 2 years of profuse vaginal bleeding. She later presents to the ED, where examination reveals invasive cervical cancer.
Triage Time Bomb
Donna L. Washington, MD, MPH; January 2004
A triage nurse instructed by a physician to immediately bring a febrile child, who was possibly dehydrated, to the treatment area is stopped by the charge nurse, citing overcrowding. The parents seek treatment elsewhere; upon arrival, the child is in full arrest.