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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Rahul Sharma, MD, MBA; and Douglas Brunette, MD, MPH; December 2011
A woman presented to the emergency department with an eyelid laceration, which was sutured without complication. Her visual acuity was not formally tested and ophthalmology was not consulted. Ten days later, she presented with eye pain and poor vision. Ophthalmologist evaluation revealed a ruptured globe requiring surgical repair.
Lisa I. Iezzoni, MD, MSc; December 2005
A man is discharged home with injections and written instructions on how to administer his medications. However, the nurse and pharmacist did not notice that he was blind.
Lorri A. Lee, MD; June 2005
A woman undergoes surgery and immediately has blurry vision, mistakenly attributed to ointment. Two weeks later, she returns complaining of blindness in one eye.