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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Susan C. Fagan, PharmD, BCPS, FCCP; April 2005
A patient with presumed stroke is given tPA before the results of her coagulation studies are known. Five minutes later, the lab reports that the INR was elevatedan absolute contraindication to thrombolytic therapy.