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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- Device-related Complications 2
- Diagnostic Errors 1
- Medical Complications
- Medication Safety 1
- Nonsurgical Procedural Complications 1
Nancy Moureau, BSN, RN, CRNI, CPUI, VA-BC; December 2012
A woman undergoing treatment for myasthenia gravis via PICC developed extensive catheter-related thrombosis, bacteremia, and sepsis, and ultimately died. Although the PICC line was placed at one facility, the patient was receiving treatment at another, raising questions about who had responsibility for the line.
Andrew S. Dunn, MD; April 2010
An elderly woman with a history of mitral valve replacement with a mechanical prosthesis was admitted to the hospital for evaluation of abdominal pain. Although an order was written to stop her blood thinner and restart it 48 hours after the procedure, the medication was not restarted.
Gurpreet Dhaliwal, MD; December 2009
Physicians confuse the terminology on a preliminary radiology report and diagnose a woman with foot and ankle pain as having a low-risk case of superficial vein thrombosis, rather than the more dangerous deep vein thrombosis she actually had.
- Spotlight Case
Adrienne G. Randolph, MD, MSc ; May 2003
An infant codes due to pulmonary emboli after a central line flush.