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 1
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- Legal and Policy Approaches 1
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- Technologic Approaches 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Interruptions and distractions 1
- Medication Errors/Preventable Adverse Drug Events 2
Tess Pape, PhD, RN, CNOR; February 2006
Bypassing the safeguards of an automated dispensing machine in a skilled nursing facility, a nurse administers medications from a portable medication cart. A non-diabetic patient receives insulin by mistake, which requires his admission to intensive care and delays his chemotherapy for cancer.
Eran Kozer, MD; June 2003
A boy given an overdose of nifedipine rather than its extended-release (XL) form suffers dangerous hypotension.