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 2
- Error Reporting and Analysis 1
- Human Factors Engineering 1
- Legal and Policy Approaches 1
- Quality Improvement Strategies 4
- Technologic Approaches 2
Howard I. Maibach, MD; January 2016
An attending physician recommended using acetic acid to evaluate a lesion on the perineum of a woman who had previously experienced a wart in the same area. The resident physician asked the medical assistant for acetic acid and unknowingly received trichloroacetic acid, which burned the patient's skin.
- Spotlight Case
Catherine Liu, MD; October 2012
A teenage athlete noticed what he thought was an insect bite on his buttock, but only mentioned it to his mother a few days later, when it was much worse. Four days after his pediatrician prescribed antibiotics for CA-MRSA, the boy wound up hospitalized with complications from CA-MRSA, including acute renal failure, respiratory failure, and osteomyelitis of the femur head requiring total hip replacement.
John Starling III, MD; March 2012
Following biopsies for two skin lesions on his left cheek, a patient was sent to an outside surgeon for excision of squamous cell carcinoma. Although the referral included a description and diagram, the wrong lesion was removed.
- Spotlight Case
Susan Barbour, RN, MS, FNP; December 2010
Admitted to the hospital with right-hip and left-arm fractures, an elderly woman remained on the same bed from the emergency department for nearly 16 hours and developed a moderate-sized, stage 2 pressure ulcer.
Ross Koppel, PhD; April 2009
A patient hospitalized with Pneumocystis jiroveci pneumonia and advanced AIDS is given another patient's malignant biopsy results, leading his primary physician to mistakenly recommend hospice care.