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 8
- Culture of Safety 4
- Education and Training 3
- Error Reporting and Analysis 1
- Human Factors Engineering 7
- Legal and Policy Approaches 1
- Logistical Approaches 4
- Quality Improvement Strategies 8
- Specialization of Care 1
- Teamwork 1
- Clinical Information Systems 4
- Alert fatigue 1
- Device-related Complications 1
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems
- Identification Errors 1
- Interruptions and distractions 1
- Delirium 1
- Medication Safety 4
- Surgical Complications 1
- Internal Medicine
- Nursing 3
- Palliative Care 1
- Pharmacy 1
Joseph G. Ouslander, MD, and Alice Bonner, PhD, GNP; December 2013
Following a lengthy hospitalization, an elderly woman was admitted to a skilled nursing facility for further care, where staff expressed concern about the complexity of the patient's illness. A few days later, the patient developed a fever and shortness of breath, prompting readmission to the acute hospital.
- Spotlight Case
Jeanne M. Farnan, MD, MHPE; and Vineet M. Arora, MD, MAPP; May 2012
Inadequate signout to the members of the night float team prevented them from appreciating a patient's mental status changes. Found comatose by the weekend cross-coverage team, the patient had a prolonged ICU stay.
Marta L. Render, MD; May 2012
After placing a central line in an elderly patient following a heart attack, a community hospital transferred him to a referral hospital for stenting of his coronary arteries. He was discharged to an assisted living facility 2 days later, with the central line still in place.
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.
Annette J. Johnson, MD, MS; October 2011
When a hospitalized man developed an arrhythmia, the night float resident checked a radiology report that stated the patient had a DVT. Intervention was started based on that assumption. However, the radiology report had been transcribed incorrectly.
- Spotlight Case
Amy A. Vogelsmeier, PhD, RN; September 2011
Following surgical repair for a hip fracture, a nursing home resident with limited mobility developed a fever. She was readmitted to the hospital, where examination revealed a very deep pressure ulcer. Despite maximal efforts, the patient developed septic shock and died.
- Spotlight Case
Margaret Fang, MD, MPH; Raman Khanna, MD, MAS; July 2011
Following hospitalization for community-acquired pneumonia, an elderly man with a history of dementia, falls, and atrial fibrillation is discharged on antibiotics but no changes to his anticoagulation medication. One week later, the patient’s INR was dangerously high.
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.
Kerm Henriksen, PhD; Kendall K. Hall, MD, MS; June 2011
Admitted to the hospital with community-acquired pneumonia, an elderly man nearly receives dangerous potassium supplementation due to a “critical panic value” call for a low potassium in another patient.
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.
- Spotlight Case
Chase Coffey, MD, MS; November 2010
A man returns to the emergency department 11 days after hospital discharge in worsening condition. With no follow-up on a urine culture and sensitivity sent during his hospitalization, the patient had been taking the wrong antibiotic for a UTI.
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.
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.
Gregg C. Fonarow, MD; September 2007
An elderly man with a history of hypertension, coronary artery disease, congestive heart failure (CHF), and countless hospital admissions for CHF came to the emergency department complaining of shortness of breath and fatigue. The admitting physician discovered that the patient had never received clear education about caring for himself outside the hospital.
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.