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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- Internal Medicine
- Medication Errors/Preventable Adverse Drug Events
- Nonsurgical Procedural Complications
- Quality and Safety Professionals
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.
- Spotlight Case
Jean L. Holley, MD ; October 2010
A man with end-stage renal disease on hemodialysis was dialyzed with equipment that had been inappropriately reused, exposing the patient to another patient's blood numerous times.