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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Robert R. Cima, MD, MA; September 2012
Following successful bypass surgery and mitral valve repair, an elderly man with diabetes, hypertension, and end-stage renal disease continued to attend hemodialysis and other clinic visits regularly. Eight months later, he was admitted to the hospital with shaking chills, confusion, and a collection of pus in his chest. A surgical procedure to free the trapped lung also uncovered a surgical instrument from the previous surgery.