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 2
- Error Reporting and Analysis 1
- Logistical Approaches 1
- Quality Improvement Strategies 4
- Technologic Approaches 2
Robert Chang, MD, and Scott Flanders, MD; February 2019
A woman was admitted to a hospital's telemetry floor for management of uncontrolled hypertension and palpitations. On the first hospital day, she complained of right arm numbness and weakness and had new difficulty answering questions. The nurse called the hospitalist and relayed the arm symptoms, but not the word-finding difficulty. The hospitalist asked the nurse to call for a neurology consultation. Four hours later, the patient's weakness had progressed; she was now completely unable to move her right arm. At that point, neither the hospitalist nor the neurology consultant had evaluated the patient in person. A stat head CT revealed a large ischemic stroke.
- Spotlight Case
Daniel J. Morgan, MD, MS, and Andrew Foy, MD; March 2017
Brought to the emergency department from a nursing facility with confusion and generalized weakness, an older woman was found to have an elevated troponin level but no evidence of ischemia on her ECG. A consulting cardiologist recommended treating the patient with three anticoagulants. The next evening, she became acutely confused and a CT scan revealed a large intraparenchymal hemorrhage with a midline shift.
Jennifer Merrilees, RN, PhD, and Kirby Lee, PharmD, MA, MAS; May 2016
An elderly man with early dementia fractured his leg and was admitted to a skilled nursing facility for physical therapy. On his third day there, he became delirious and agitated and was taken to the emergency department and hospitalized. A few days later, doctors involuntarily committed him and administered risperidone, which worsened his delirium.
- 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.
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.
S. Andrew Josephson, MD; April 2008
A man hospitalized for acute intracranial hemorrhage and cerebral edema was continued too long on an intravenous diuretic. He developed severe dehydration, hypernatremia, and renal failure.