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
- Quality Improvement Strategies 1
- Specialization of Care 3
- Technologic Approaches 2
Scott D. Nelson, PharmD, MS; March 2017
Although meningitis and neurosyphilis were ruled out for a woman presenting with a headache and blurry vision, blood tests returned indicating latent (inactive) syphilis. Due to a history of penicillin allergy, the patient was sent for testing for penicillin sensitivity, which was negative. The allergist placed orders for neurosyphilis treatment—a far higher penicillin dose than needed to treat latent syphilis, and a treatment regimen that would have required hospitalization. Upon review, the pharmacist saw that neurosyphilis had been ruled out, contacted the allergist, and the treatment plan was corrected.
Steven R. Kayser, PharmD; February 2007
A woman admitted to the hospital for cardiac transplantation evaluation is mistakenly given warfarin despite an order to hold the dose due to an increase in her INR level.
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.