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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- Device-related Complications 1
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- Discontinuities, Gaps, and Hand-Off Problems 4
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- Spotlight Case
Joseph I. Boullata, PharmD, RPh, BCNSP; April 2013
A 3-year-old boy hospitalized with anemia who was on chronic total parenteral nutrition was given an admixture with a level of sodium 10-fold higher than intended. Despite numerous warnings and checks along the way, the error still reached the patient.
Erika Abramson, MD, MS, and Rainu Kaushal, MD, MPH; September 2011
Antibiotics administration for an elderly man hospitalized for acute infection is delayed by more than 24 hours due to a mix-up and override in the computerized provider order entry system. However, none of the clinicians on the floor questioned the delay.
Ben-Tzion Karsh, PhD; March 2011
A patient requiring orthopedic follow-up after an emergency department visit missed his appointment, and a secretary canceled the referral in the electronic medical record to minimize black marks on the hospital’s 30-day referral quality scorecard. Because the primary physician did not receive notice of the cancellation, follow-up was delayed.
Annie Wong-Beringer, PharmD; December 2010
A patient on palliative chemotherapy was given intravenous vancomycin for methicillin-resistant staphylococcus aureus (MRSA), despite a rising creatinine level, and went into acute kidney failure.
Hardeep Singh, MD, MPH; Dean F. Sittig, PhD; Maureen Layden, MD, MPH; November 2010
At two different hospitals, patients were instructed to continue home medications, even though their medication lists had errors that could have led to significant adverse consequences.
Rainu Kaushal, MD, MPH; Erika Abramson, MD ; August 2009
The theophylline dose of a patient admitted for COPD exacerbation and pneumonia is doubled, and he develops atrial flutter with a rapid ventricular response, chest pain, and increased shortness of breath.
William W. Churchill, MS, RPh; Karen Fiumara, PharmD; April 2009
A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
Timothy W. Cutler, PharmD; February-March 2009
A 91-year-old woman is found lethargic and incontinent, with slurred speech. Review of her medications reveals numerous duplicates, including some considered potentially inappropriate for use in elderly patients.
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.