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 5
- Education and Training 2
- Human Factors Engineering 2
- Quality Improvement Strategies 1
- Specialization of Care 2
- Technologic Approaches 5
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 1
- Medical Complications 2
- Medication Safety 6
- Nonsurgical Procedural Complications 3
Matthew J. Doyle, MBBS; April 2017
Prior to undergoing a CT scan, a patient with no allergies documented in the electronic health record (EHR) described a history of hives after receiving contrast. During a follow-up clinic visit, the patient inquired whether this contrast reaction was listed in the EHR. Investigation revealed that it had been removed from the patient's profile, thus leaving the record with no evidence of allergy to contrast.
Scott D. Nelson, PharmD, MS; March 2017
Although meningitis and neurosyphilis were ruled out for a woman presenting with a headache and blurry vision, blood tests returned indicating latent (inactive) syphilis. Due to a history of penicillin allergy, the patient was sent for testing for penicillin sensitivity, which was negative. The allergist placed orders for neurosyphilis treatment—a far higher penicillin dose than needed to treat latent syphilis, and a treatment regimen that would have required hospitalization. Upon review, the pharmacist saw that neurosyphilis had been ruled out, contacted the allergist, and the treatment plan was corrected.
The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy
- Spotlight Case
Jacob Reider, MD; October 2015
After leaving Hospital X against medical advice, a man with paraplegia presented to the emergency department of Hospital Y with pain and fever. The patient was diagnosed with sepsis and admitted to Hospital Y for management. In the night, the nurse found the patient unresponsive and called a code blue. The patient was resuscitated and transferred to the ICU, where physicians determined that the arrest was due to acute rupturing of his red blood cells (hemolysis), presumably caused by a reaction to the antibiotic. Later that day, the patient's records arrived from three hospitals where he had been treated recently. One record noted that he had previously experienced a life-threatening allergic reaction to the antibiotic, which was new information for the providers at Hospital Y.
Russ Cucina, MD, MS; July 2006
Despite full documentation and a wristband regarding her severe food allergy, an inpatient is advertently fed eggs and suffers an allergic reaction.
Richard Cohan, MD; September 2004
Prior to a CT scan, a patient states that he is not allergic to x-ray dye. Soon after injection, he goes into anaphylactic shock.
Mark V. Williams, MD; July 2004
A man sent for a Holter monitor inadvertently arrives at the allergy clinic and receives a skin test instead.
- Spotlight Case
Thomas H. Gallagher, MD; Wendy Levinson, MD; June 2004
A child is mistakenly vaccinated for hepatitis A, rather than B. Despite forthright disclosure and no evident harm to the child, the father becomes incredibly angry at the providers.
Hilary M. Babcock, MD; Victoria J. Fraser, MD; June 2003
Antibiotics continued in a patient with no clear source of infection for 3 weeks results in hospital-acquired superinfections.