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
- Education and Training 1
- Error Reporting and Analysis 2
- Human Factors Engineering 1
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Technologic Approaches 1
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Medication Errors/Preventable Adverse Drug Events 2
- Nonsurgical Procedural Complications 1
- Spotlight Case
Joseph O. Jacobson, MD, MSc, and Saul N. Weingart, MD, PhD; May 2013
A cancer patient expecting to be discharged from the hospital after his usual 3-day regimen was surprised to hear that he has 2 more days of chemotherapy. He asked to speak with the oncology team, who discovered that although the right medications were ordered, the wrong duration and dosage were selected on the order set.
Roy Ilan, MD, MSc; May 2013
A woman was emergently admitted for surgery for acute appendicitis. Although the patient had a chest port for breast cancer chemotherapy, the surgeon demanded that a peripherally inserted central catheter (PICC) be placed. The patient developed blood clots from the PICC, and surgery was cancelled. Significant complications, including perforation, peritonitis, and prolonged hospitalization, arose from managing the appendicitis conservatively.
John Lubel, MD; November 2011
A woman undergoing chemotherapy for breast cancer developed fulminant liver failure after clinicians failed to check whether she had a history of hepatitis.
Debora Simmons, PhD, RN; September 2011
Following surgery, a cancer patient was receiving total parenteral nutrition and lipids through a central venous catheter and pain control through an epidural catheter. A nurse mistakenly connected a new bottle of lipids to the epidural tubing rather than the central line, and the error was not noticed for several hours.
John Q. Young, MD, MPP; July 2011
A healthy elderly man presented to his primary care doctor—a third-year internal medicine resident—for routine examination. A PSA test was markedly elevated, but the results came back after the resident had graduated, and the alert went unread. Months later, the patient presented with new onset low back pain and was diagnosed with metastatic prostate cancer.