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 between Providers
- Sbar 1
- Communication between Providers 80
- Culture of Safety 8
- Education and Training 35
- Error Reporting and Analysis 17
Human Factors Engineering
- Checklists 13
- Legal and Policy Approaches 14
- Logistical Approaches 16
- Quality Improvement Strategies 61
- Specialization of Care 13
- Teamwork 7
- Clinical Information Systems 42
- Alert fatigue 2
- Device-related Complications 21
- Diagnostic Errors 48
- Discontinuities, Gaps, and Hand-Off Problems 65
- Failure to rescue 1
- Identification Errors 9
- Interruptions and distractions 7
- Delirium 4
- Medication Errors/Preventable Adverse Drug Events 44
- Nonsurgical Procedural Complications 16
- Psychological and Social Complications 8
- Surgical Complications 14
- Transfusion Complications 3
- Ambulatory Care 27
- Hospitals 163
- Long-Term Care 8
- Outpatient Surgery 2
- Patient Transport 3
- Psychiatric Facilities 1
- Gynecology 23
- Cardiology 40
- Geriatrics 33
- Pulmonology 13
- Pediatrics 11
- Primary Care 12
- Nursing 16
- Palliative Care 3
- Pharmacy 8
- Health Care Executives and Administrators 84
Health Care Providers
- Nurses 13
- Physicians 34
- Non-Health Care Professionals 37
- Patients 3
Lisa I. Iezzoni, MD, MSc; December 2005
A man is discharged home with injections and written instructions on how to administer his medications. However, the nurse and pharmacist did not notice that he was blind.
Jeffrey M. Pearl, MD; Nancy E. Donaldson RN, DNSc; July-August 2005
A nurse preparing a patient for transfer out of the ICU discovers the guidewire used for central line placement (1 week earlier) still in the patient's leg vein.
Susan C. Fagan, PharmD, BCPS, FCCP; April 2005
A patient with presumed stroke is given tPA before the results of her coagulation studies are known. Five minutes later, the lab reports that the INR was elevatedan absolute contraindication to thrombolytic therapy.
- Spotlight Case
David M. Gaba, MD ; October 2004
A dyspneic patient fails to improve after being placed on high-flow oxygen. The respiratory therapist soon discovers why: the patient is mistakenly receiving compressed room air.
- Spotlight Case
Elizabeth B. Lamont, MD, MS; September 2004
Following hernia repair surgery, an elderly woman is incidentally found to have a mass in her neck. Expecting the worst, the treating physician recommends palliative care and withdrawal of mechanical ventilation, before biopsy results are in.
Richard Cohan, MD; September 2004
Prior to a CT scan, a patient states that he is not allergic to x-ray dye. Soon after injection, he goes into anaphylactic shock.
Mark V. Williams, MD; July 2004
A man sent for a Holter monitor inadvertently arrives at the allergy clinic and receives a skin test instead.
Douglas B. Nelson, MD; July 2004
Prior to colonoscopy, a woman is found unresponsive after completing her bowel prep regimen.
Tom Bookwalter, PharmD; June 2004
A woman given is found cyanotic on morning rounds. Her methemoglobinemia is determined to be from a roughly 7-fold overdose of dapsone.
- Spotlight Case
Thomas H. Gallagher, MD; Wendy Levinson, MD; June 2004
A child is mistakenly vaccinated for hepatitis A, rather than B. Despite forthright disclosure and no evident harm to the child, the father becomes incredibly angry at the providers.
Michael Astion, MD, PhD; June 2004
Just before leaving for the weekend, a physician orders a test for a communicable infection. Although the result arrives and isolation signs are placed on the patient's door, none of the covering physicians are notified, and the float nurses mistakenly assume the patient is already receiving treatment.
J. Mark FitzGerald, MB; Dick Menzies, MD; May 2004
A woman hospitalized for 3 weeks with a respiratory infection was not responding to broad-spectrum antibiotics. Tragically, she died a few days before test results revealed that she actually had tuberculosis.
Arpana Vidyarthi, MD; March 2004
Due to a series of incomplete signouts, information about a patient's post-operative leg pain and chest discomfort is not conveyed to the primary team. A PE is discovered post-mortem.
Darren R. Linkin, MD; Ebbing Lautenbach, MD, MPH, MSCE; February 2004
Infection Control notices an uptick in post-operative wound infections for patients from one OR team. Environmental rounds reveal "sloppy" practices.
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.
Marc J. Shapiro, MD; February 2004
Trusting an incorrectly labeled chest x-ray over physical exam findings, a resident places a chest tube for pneumothorax in the wrong side.
J. Forrest Calland, MD; January 2004
During a hernia repair, surgeons decide to remove a patient's hydrocele, spermatic cord, and left testiclewithout realizing that his right testicle had been removed previously.
Timothy S. Lesar, PharmD; November 2003
An unclear verbal order leads to administration of the wrong drug.
Hilary M. Babcock, MD; Victoria J. Fraser, MD; June 2003
Antibiotics continued in a patient with no clear source of infection for 3 weeks results in hospital-acquired superinfections.
Eran Kozer, MD; June 2003
A boy given an overdose of nifedipine rather than its extended-release (XL) form suffers dangerous hypotension.