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
- Education and Training 2
- Error Reporting and Analysis 2
- Human Factors Engineering 1
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 3
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 3
- Identification Errors 1
- Medical Complications 2
- Medication Safety 2
- Psychological and Social Complications 1
- Surgical Complications 1
Harriette Gillian Christine Van Spall, MD; Robby Nieuwlaat, PhD; and R. Brian Haynes, MD, PhD; July 2011
A man with HIV disease and a recent diagnosis of CNS toxoplasmosis presented to the ED for the third time in two weeks with headaches, seizures, and right-sided weakness. Physicians pursued a workup for treatment-resistant toxoplasmosis or another brain disease, but discovered that the patient had run out of his toxoplasmosis medications.
- 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.
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.
Leslie W. Hall, MD; October 2008
Orthopedic surgeons rounding on an elderly Cantonese-speaking woman recommend conservative, nonsurgical treatment for her broken hip, as their examination noted that the patient was able to walk. Given that strict bed rest orders were in place for this patient, a medical intern found the note peculiar. Further investigation revealed that the surgeons had actually walked the patient's roommate, another Cantonese-speaking woman.
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.
J. Forrest Calland, MD; January 2004
During a hernia repair, surgeons decide to remove a patient's hydrocele, spermatic cord, and left testiclewithout realizing that his right testicle had been removed previously.