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 4
- Culture of Safety 1
- Education and Training 1
- Legal and Policy Approaches 1
- Specialization of Care 1
- Teamwork 2
- Technologic Approaches 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medication Safety 2
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 3
- Surgical Complications 1
- Spotlight Case
Abigail Zuger, MD; June 2011
An adolescent girl passed out after a soccer game, and her father, a physician, took her to the pediatrician for tests. The physician father obtained a copy of his daughter’s ECG, panicked because it was not normal, and began guiding his daughter’s medical care.
- Spotlight Case
Ernest J. Ring, MD; Jane E. Hirsch, RN, MS; October 2009
Cardiology consultation on an elderly man admitted to the orthopedic service following a hip fracture reveals aortic stenosis. The cardiologist recommends against surgery, due to the risk of anesthesia. When the nurse reads these recommendations to the orthopedic resident, he calls her "stupid" and contacts the OR to schedule the surgery anyway. The Chief Medical Officer is called to intervene.
Dorrie K. Fontaine, RN, PhD; October 2009
A toddler admitted for severe dehydration requires a femoral IV. The anesthesiologist ignores a nurse's reminder that hospital policy requires monitoring if a child is to receive sedation in the unit. When the nurse attempts to stop the procedure, the anesthesiologist throws the needle to the floor.
Timothy S. Lesar, PharmD; November 2003
An unclear verbal order leads to administration of the wrong drug.