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 3
- Culture of Safety 2
- Error Reporting and Analysis 1
- Human Factors Engineering 1
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Technologic Approaches
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 3
- Interruptions and distractions 1
- Medication Safety 2
- Surgical Complications 2
Robert R. Cima, MD, MA; September 2012
Following successful bypass surgery and mitral valve repair, an elderly man with diabetes, hypertension, and end-stage renal disease continued to attend hemodialysis and other clinic visits regularly. Eight months later, he was admitted to the hospital with shaking chills, confusion, and a collection of pus in his chest. A surgical procedure to free the trapped lung also uncovered a surgical instrument from the previous surgery.
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.
Robert J. Weber, PharmD, MS; February 2010
An elderly woman presented to the emergency department following a hip fracture. Although the patient's medication bottles were used to generate a medication list, one of the dosages was transcribed incorrectly. Because the patient then received four times her regular dose, her surgery was delayed due to cardiac side effects.
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.