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
- Culture of Safety 2
- Human Factors Engineering 2
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Specialization of Care 1
- Technologic Approaches 3
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 3
- Identification Errors 2
- Interruptions and distractions 1
- Medication Safety 1
- Nonsurgical Procedural Complications 1
- Surgical Complications 1
Kerm Henriksen, PhD; Kendall K. Hall, MD, MS; June 2011
Admitted to the hospital with community-acquired pneumonia, an elderly man nearly receives dangerous potassium supplementation due to a “critical panic value” call for a low potassium in another patient.
Leslie W. Hall, MD; October 2008
Orthopedic surgeons rounding on an elderly Cantonese-speaking woman recommend conservative, nonsurgical treatment for her broken hip, as their examination noted that the patient was able to walk. Given that strict bed rest orders were in place for this patient, a medical intern found the note peculiar. Further investigation revealed that the surgeons had actually walked the patient's roommate, another Cantonese-speaking woman.
Arpana Vidyarthi, MD; March 2004
Due to a series of incomplete signouts, information about a patient's post-operative leg pain and chest discomfort is not conveyed to the primary team. A PE is discovered post-mortem.
Timothy S. Lesar, PharmD; November 2003
An unclear verbal order leads to administration of the wrong drug.